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

Two-thirds of deaths occurred in hospitals, with more than half of the women dying after giving birth. Photograph: David Jones/PA

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

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”.