Research conducted by King’s College in London, and published in the BMJ Gynecology and Obstetrics Clinical Medicine, has found that two thirds of Prevention of Future Deaths reports following the death of a pregnant woman or a new mum are ignored.
A Prevention of Future Deaths report includes recommendations from a coroner on the actions to be taken to avoid the loss of lives. The NHS has a time limit within which it must respond with evidence of the actions implemented to provide safe patient care. The purpose is to avoid more serious incidents leading to the death of more patients.
The investigation found that only 38% of Future Death Reports, available to the public, had published responses during the period between 2013 – 2023.
The findings are concerning as some of the deaths could potentially have been avoided with better care. The top three concerns raised by coroners were found to be:
- Failing to escalate care
- Failing to provide appropriate medical care
- A lack of training
With a national maternity review, and an increasing number of local investigations into hospital maternity units currently underway, the latest findings raise significant concerns around the safety of care delivered in hospitals.
For families who have suffered the loss of a mother, a baby, or for those who have survived a serious maternity incident that has left their baby permanently disabled, the lack of accountability raises questions around if, how and when the necessary changes will take place.
Previous high profile maternity investigations, including the Morecambe Bay and Shropshire reviews, have failed to deliver the needed change to ensure safe maternity care for families.
The same failings are being repeated in hospitals across England and Wales leading to catastrophic outcomes for families who deserve better.
Until robust accountability is put in place, lessons will not be learned, much needed improvements will not be made, and mothers and babies will continue to suffer serious harm that could potentially have been prevented had adequate measures been implemented.