Proceedings from the 43rd MacDonald Obstetric Medicine Society Meeting2.11.23

Background: Coroners in England and Wales publish Prevention of Future Death (PFD) reports when they believe action should be taken to prevent similar deaths from occurring, and organisations have a duty to respond within 56 days. These reports are publicly available, but under-utilised and poorly disseminated. Methods: We used an established and reproducible web-scraping and case-screening method using openly available code to screen 4411 PFDs from 1st July 2013 (inception) - 1st June 2023 for maternal deaths. We extracted demographic information, coroner ’ s concerns, and organisational responses, and employed directed content analysis to identify common themes. Results: We identi fi ed 29 PFDs concerning maternal deaths. The mean age of death was 34 years and 76% occurred in hospital. The most common causes of death were suicides and consequences of thromboembolism (6 cases each). The most frequent risk factor identi fi ed was extremes of age (<17 years or >35 years). Death most commonly occurred during the antepartum period. Coroners frequently voiced concerns around poor multidisciplinary working (59% of PFDs), failure to provide appropriate treatment (48%) and failure of timely escalation (38%). Only 38% of PFDs received a response from the organisation to which they were sent. When organisations did respond, 85% of responses implemented new changes including publishing new local policies, increasing multidisciplinary training in obstetric scenarios, or committing to increasing staf fi ng levels. Conclusions: PFDs can highlight gaps in obstetric care which, if appropriately addressed, could prevent future maternal deaths. However, the low response rate to reports suggest lessons are not being learnt