Coroners’ advice on maternal deaths in England and Wales routinely ignored, study finds

The advice given by coroners in England and Wales to help prevent maternal deaths is not being acted upon, research suggests.

A study by academics at King’s College London looked at prevention of future deaths (PFD) reports issued by coroners in cases of pregnant women and new mothers who died between 2013 and 2023. They found these reports were not being “systematically used nationally”.

NHS organisations, like other professional bodies, are legally required to reply to the coroner within 56 days, but the study found only 38% of PFDs had published responses from the organisations they were sent to.

Two-thirds of deaths occurred in hospitals, with more than half of the women dying after giving birth. The most common causes of death were haemorrhage, complications during early pregnancy and suicide.

Concerns raised by coroners most frequently included failing to provide appropriate treatment or to escalate cases, and lack of training.

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Source: The Guardian (19 November 2025)