The most common cause of death was haemorrhage while one in five women took their own life
Advice issued by coroners to prevent pregnant women and new mothers dying is not being acted upon, researchers have warned. The study by experts at Kings College London (KCL) found the gaps in care being recognised by professionals are not being “systematically used nationally” to avoid future tragedies.
For the study, researchers looked at prevention of future deaths (PFDs) reports which are issued by coroners if they believe action can be taken to prevent deaths – in England and Wales between 2013 and 2023. Some 29 cases involved maternal deaths, most of which took place in hospitals, with more than half of the women dying after giving birth.
The most common cause of death was haemorrhage (27%), while one in five women took their own life. Some 20% 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% reports), as well as and a failure of timely escalation (37.9% reports). Almost a third (31%) of reports flagged a lack of staff training.
However, only 38% of PFDs had published responses from the organisations they were sent to, researchers said. They added: “When organisations did respond to the coroner, 80% 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. A Department for Health and Social Care spokesperson said: “Prevention of Future Death reports are essential so that mistakes are not repeated, so it is unacceptable for organisations not to respond promptly to them.
“Too many families have been devastated by serious failings in NHS maternity and neonatal care. That is why we have commissioned an urgent national independent investigation and are setting up a taskforce, chaired by the Secretary of State, to root out systemic failures and deliver a plan for real change in maternity and neonatal care across the country.
“We are also taking immediate action to improve safety across maternity and neonatal care, including through advanced monitoring systems and programmes to prevent brain injuries during childbirth.”
