Overview
- Researchers identified 29 Prevention of Future Deaths reports tied to maternal deaths from 2013–2023, yet only 38% had published organisational responses despite a 56‑day legal requirement.
- When organisations did reply, 80% reported changes such as new local policies, additional training or commitments to increase staffing.
- Coroners most often cited failures in appropriate treatment (48.2%), delayed escalation (about 38%), and inadequate staff training (31%), highlighting recurring system weaknesses.
- Two thirds of the deaths occurred in hospitals, more than half were postpartum, and leading causes included haemorrhage (27%), suicide (about one in five), and early‑pregnancy complications (20%).
- The national maternity and neonatal investigation confirmed it will review relevant PFDs, while the Department of Health called non‑responses unacceptable, as England’s 2021–23 maternal death rate stood at 12.82 per 100,000 births.