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New research suggests that prevention guidance provided by coroners following maternal deaths in England and Wales are not being acted upon.

Key Findings from the Study

Researchers from King's College London examined prevention of future deaths reports issued by medical examiners involving expectant mothers and new mothers who passed away between 2013 and 2023.

The study, published in a prominent medical journal, identified 29 prevention of future death reports related to maternal deaths, but revealed that nearly two-thirds of these recommendations were not implemented.

Alarming Data and Trends

Two-thirds of these deaths took place in medical facilities, with more than half of the women dying after giving birth.

The most common causes of death included:

• Haemorrhage
• Problems during early pregnancy
• Self-harm

Coroners' Main Worries

Issues raised by coroners commonly featured:

• Inability to deliver appropriate care
• Lack of case escalation
• Insufficient medical training

Compliance Rates and Legal Requirements

Healthcare providers, like other regulatory organizations, are legally required to respond to the medical examiner within eight weeks.

However, the research found that merely 38 percent of PFDs had publicly available responses from the organizations they were sent to.

Worldwide and Local Context

Based on recent figures from the WHO, about 260,000 women passed away throughout and following childbirth and pregnancy, even though most of these instances could have been prevented.

While the vast majority of maternal deaths happen in developing nations, the danger of maternal death in developed nations is on average 10 per 100,000 live births.

In England, the maternal mortality rate for 2021/23 was twelve point eight two per hundred thousand live births.

Professional Commentary

"The concerns of mothers and expectant individuals must be given proper attention," stated the principal researcher of the study.

The researcher emphasized that prevention reports should be included as part of the forthcoming official inquiry into maternity services to ensure that the identical mistakes and fatalities do not occur again.

Personal Tragedy Illustrates Systemic Problems

One relative described their story: "Postpartum psychosis can be fatal if not dealt with swiftly and properly."

They added: "Unless insights aren't being learned then it's likely other women are slipping through the net."

Official Response

A representative from the official inquiry stated: "The objective of the official review is to pinpoint the underlying problems that have caused negative results, including deaths, in maternity and neonatal care."

A government health department spokesperson described the failure of organizations to respond promptly to PFDs as "unacceptable."

They confirmed: "Authorities are implementing urgent measures to improve safety across maternal healthcare, including through sophisticated tracking technology and initiatives to avoid brain injuries during childbirth."