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advice from Coroners is designed to prevent deaths of pregnant women and new mothers on which action is not being taken researcher Have warned.
A study by King’s College London (KCL) found that critical gaps in care identified by professionals “are not being systematically exploited at a national level” to prevent future tragedies.
The research examined Prevention of Future Deaths (PFD) reports issued by coroners in England and Wales from 2013 to 2023, which highlight actions to prevent further deaths.
Of these, 29 cases were related to maternal deaths, the majority of which occurred in hospitals and more than half of the women died delivery,
The most common cause of death was bleeding (27 percent), while one in five women took their own life.
About 20 percent of women died early pregnancyWhich also includes complications from termination or ectopic pregnancy.
According to the researchers, coroners “often expressed concern” about failure to provide appropriate treatment (48.2 percent reported), with failure to escalate timely (37.9 percent reporting) also being cited.
Nearly a third (31 percent) of reports cited a lack of staff training.
However, the researchers said that only 38 percent of PFDs had published responses from the organizations to which they were sent.
He added: “When organizations responded to the coroner, 80 per cent reported they had 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, said: “Every maternal death is a tragedy, a failure for the mother, her family and her baby.
“By tracking PFDs following maternal deaths, we can identify recurring concerns and shortcomings where organizations should act to save lives.
“This information should not be used to scare people giving birth or new and soon-to-be mothers. Instead, it should be used to drive action, to continue and intensify ongoing efforts to improve the treatment and management of people during this period.
“Given that gaps identified by coroners during death investigations are not being systematically used nationally, we have identified trends and patterns that should be addressed and regularly monitored to prevent similar deaths.
“The voices of mothers and pregnant people must be taken seriously.”
Richard Bash, whose wife Alex took her own life in 2022 after giving birth to their daughter Rosie, now three, said: “Alex had no mental health problems when we had our first child. A month after Rosie was born, Alex’s mental health took a sudden downturn. She had no previous history, a strong family network and no red flags.”
The development manager for Action on Postpartum Psychosis, who is also father to six-year-old Freddie, said his wife had “slipped through the net”.
He added that Alex had gone to her GP on Monday and been prescribed antidepressants, “which may take a while to have an effect”.
While the doctor arranged for Alex to see a psychologist over the weekend, Mr. Bash believes he should have been sent to the hospital for evaluation.
Instead he was sent home and took his own life on the evening of 24 October 2022.
Mr Bash, from Witney, said: “Baby blues is used as a redundant term, but postnatal 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 sad that her GP didn’t listen to her. Alex was behaving strangely and she was a siren for help. If lessons aren’t being learned, chances are other women like Alex are falling into the trap.”
The maternal mortality 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.