LONDON, United Kingdom – A new study has found that official warnings issued by coroners in England and Wales to prevent future maternal deaths are being systematically ignored. On Tuesday, 19 November 2025, researchers from King’s College London published findings in the BMJ Gynecology and Obstetrics Clinical Medicine indicating that nearly two-thirds of these critical reports receive no formal response from the healthcare organizations they are sent to. This raises significant questions about institutional accountability and learning from preventable tragedies within the UK's National Health Service (NHS).

The decade-long study, spanning from July 2013 to August 2023, analyzed 29 'Prevention of Future Deaths' (PFD) reports related to maternal fatalities. These reports are a statutory duty for coroners following an inquest where they identify a risk of similar future deaths. Despite a legal requirement for NHS organizations and other professional bodies to respond within 56 days, the research revealed that only 38% of the PFDs had a published response. The most common causes of death cited in the reports were haemorrhage, complications in early pregnancy, and suicide.

This failure to act on expert recommendations in a high-income country provides a stark parallel to the challenges faced in Kenya, where maternal mortality remains a significant public health crisis. According to the World Health Organization (WHO), the vast majority of maternal deaths occur in lower and middle-income countries. In 2020, Kenya's maternal mortality ratio (MMR) was reported at 530 deaths per 100,000 live births, far exceeding the global average of 223. More recent estimates from 2023 place Kenya's MMR at 379 per 100,000 live births. In contrast, the maternal death rate in England for 2021/23 was 12.82 per 100,000 births.

Systemic Failures and Local Relevance

The concerns raised by UK coroners—such as failures in providing appropriate treatment, delays in escalating critical cases, and inadequate staff training—echo the systemic issues plaguing Kenya's healthcare sector. In Kenya, the leading causes of maternal death include postpartum haemorrhage (accounting for up to 40% of deaths), infections, and hypertensive disorders. These are largely preventable conditions that underscore persistent gaps in access to quality care, skilled birth attendance, and emergency obstetric services.

Successive Kenyan governments have launched initiatives aimed at curbing these preventable deaths. Recently, the Ministry of Health mandated that all healthcare facilities must systematically document and audit every infant and maternal death to better understand and address the causes. Health Cabinet Secretary Aden Duale stated in early November 2025 that the government is realigning the entire health system to deliver tangible results and that failure to report accurate data would be treated as a criminal offense under the Digital Health Act. This move mirrors the accountability mechanism that the UK's PFD reports are intended to provide, highlighting a shared recognition of the need for robust surveillance and response systems.

However, challenges in Kenya remain deeply entrenched. They include inadequate funding for maternal health facilities, a shortage and inequitable distribution of skilled health workers, poverty, poor infrastructure, and cultural barriers. A 2014 audit of maternal death reviews in Kenya revealed significant weaknesses, including poor data collection and a lack of knowledge in classifying causes of death, issues which hamper effective response strategies.

Global Context and the Path Forward

The WHO's global target under the Sustainable Development Goals is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. While global MMR has dropped by about 40% between 2000 and 2023, progress has slowed, and an estimated 260,000 women died during or after pregnancy in 2023. Sub-Saharan Africa alone accounted for approximately 70% of these deaths.

The findings from the King's College London study underscore that even in well-resourced health systems, translating lessons from tragedies into concrete action is not guaranteed. For Kenya, where the stakes are significantly higher, the UK's experience serves as a critical reminder that policy and legal frameworks for accountability must be rigorously enforced. As Homa Bay County has demonstrated with its USAID-funded audit program, investigating every death can identify crucial gaps in equipment and skills, leading to targeted improvements.

Dr. Georgia Richards, the lead author of the UK study, emphasized that the findings should be used to address failings and accelerate efforts to prevent similar deaths. This sentiment is equally urgent in the Kenyan context. As the government moves to digitize and enforce maternal death surveillance, the focus must be on creating a closed-loop system where audit findings lead directly to well-resourced, actionable changes that save the lives of mothers and newborns across the country.