Preventable maternal deaths in England and Wales, 2013–2023: a systematic case series of coroners’ reports (4 November 2025)

Summary

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. This article sets out the findings of a systematic case series study of the reports involving maternal deaths. It sought 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.

Content

Key findings

• The median age at death was 33.5 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 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.
• There is no mechanism to follow-up on missing responses or ensure that reported actions are implemented.

Related reading

• Preventable deaths tracker
• Independent maternity and neonatal investigation: terms of reference