Preventable maternal deaths in England and Wales, 2013–2023: a systematic case series of coroners’ reports

Objectives Coroners in England and Wales have a duty to write Prevention of Future Deaths (PFDs) reports when they believe that action should be taken to prevent similar deaths. We conducted a systematic case series of the reports involving maternal deaths to characterise these deaths in terms of demographics, explore the concerns raised by the coroners and understand what actions were reported by organisations in their responses to the coroner. Methods All coroners’ PFDs published between July 2013 and 1 August 2023 in England and Wales were collected and reviewed (n=4435). Reports were searched for keywords related to maternal deaths. Case information was extracted into pre-specified domains and compared to other data on maternal deaths. Results Twenty nine (n=29) cases were found involving a maternal death. The median age at death was 33.5 years (IQR 29–36 years) and three-quarters (75.9%) of deaths occurred in hospitals. The most common cause of death was haemorrhage. Coroners frequently voiced concerns around the failure to provide appropriate treatment (48.2%) and failure of timely escalation (37.9%). Specific lessons we have highlighted include gaps in national guidance, failure to follow national protocols, communication issues and lack of resources or staff cover. Only 38% of PFDs had published responses from the organisations they were sent to. 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. Conclusions Poor response rates to PFDs indicate under-utilisation of these reports as a resource for improvement in maternal care. PFDs highlighted gaps in obstetric care and national guidance which, if appropriately addressed and regularly and routinely monitored, could prevent similar deaths.