Preventable Maternal Deaths in England and Wales 2013–2023 – a systematic case series of coroners' reports

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 the cases, causes of deaths, risk factors, concerns and organisational responses. The sample included all coroners PFDs published between July 2013 and 1 August 2023. There were 4435 reports at the time of data collection. A reproducible computer code developed from the Preventable Deaths Tracker was used to download all published PFDs from the Judiciary website. 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. Twenty nine (29) reports involved a maternal death. The median age at death was 33.5 years (IQR 29-36 years) and 76% of deaths occurred in hospitals. The most common cause of death was haemorrhage. Coroners frequently voiced concerns around failure to provide appropriate treatment (57%), and failure of timely escalation (38%). Only 38% of PFDs received published responses from the organisations they were sent to, highlighting the underutilisation of these reports. 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. PFDs highlighted gaps in obstetric care and national guidance which, if appropriately addressed, and regularly and routinely monitored, could prevent similar deaths.