Warning issued as coroners’ advice to prevent deaths of pregnant women ‘not being acted on’

Advice from coroners designed to prevent the deaths of pregnant women and new mothers is not being acted upon, researchers have warned.

A study by King’s College London (KCL) found that critical gaps in care, identified by professionals, are not being “systematically used nationally” to avert future tragedies.

The research examined Prevention of Future Deaths (PFDs) reports issued by coroners in England and Wales from 2013 to 2023, which highlight actions to prevent further fatalities.

Among these, 29 cases involved maternal deaths, with the majority occurring in hospitals and over half of the women dying after childbirth.

The most common cause of death was haemorrhage (27 per cent), while one in five women took their own life.

Some 20 per cent of women died in early pregnancy, including from complications from terminations or ectopic pregnancies.

According to researchers, coroners “frequently voiced concerns” about a failure to provide appropriate treatment (48.2 per cent reports), as well as and a failure of timely escalation (37.9 per cent reports) were also cited.

Almost a third (31 per cent) of reports flagged a lack of staff training.

However, only 38 per cent of PFDs had published responses from the organisations they were sent to, researchers said.

They added: “When organisations did respond to the coroner, 80 per cent reported that they implemented changes, including publishing new local policies, increasing training or committing to increased staffing.”

Dr Georgia Richards, research fellow in the faculty of life sciences and medicine at KCL, added: “Every maternal death is a tragedy, a failure to the mother, their family and their child.

“By tracking PFDs following maternal deaths, we can identify repeated concerns and gaps where organisations should act to save lives.

“These insights should not be used to terrify people giving birth or new and soon-to-be mothers. Instead, it should be used for action, to continue and accelerate ongoing efforts that must improve how people are treated and managed during this period.

“The gaps recognised by coroners during death investigations are not being systematically used nationally, we identified trends and patterns that must be addressed, and routinely monitored, to prevent similar deaths.

“The voices of mothers and pregnant people must be taken seriously.”

Richard Baish, whose wife Alex took her own life in 2022 after giving birth to their daughter, Rosie, now three, said: “Alex had no mental health issues when we had our first child. A month after Rosie was born, Alex had a sudden downturn in her mental health. She had no previous history, a strong family network and no red flags.”

The development manager at Action on Postpartum Psychosis, who is also father to Freddie, six, said his wife “slipped through the net”.

He added that Alex had gone to her GP on the Monday and was prescribed antidepressants, “which would have taken a little while to kick in”.

While the doctor arranged for Alex to see a psychologist later in the week, Mr Baish believes she should have been sent to hospital to be assessed.

Instead she was sent home and took her own life that evening, on October 24 2022.

Mr Baish, from Witney, said: “Baby blues is used as a throwaway term but postpartum psychosis can be life-threatening if not dealt with swiftly and appropriately.

“There were no red flags for Alex, which is why it was so tragic her GP didn’t listen to her. Alex was acting strangely and that was the siren for help. If lessons aren’t being learnt then it’s likely other women like Alex are slipping through the net.”

The maternal death rate in England for 2021/23 was 12.82 per 100,000 women giving birth.

Dr Richards said PFDs should be included in the upcoming maternity review led by Baroness Amos.

The independent investigation was ordered by Health Secretary Wes Streeting and will focus on 14 NHS trusts.