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Maternal death: learning from maternal death investigations during the first wave of the COVID-19 pandemic


The national investigation

We have carried out a themed review of our maternal death investigations during the coronavirus (COVID-19) pandemic.

Our national learning reports can be used by healthcare leaders, policymakers, and the public to:

  • Aid their knowledge of systemic patient safety risks
  • Understand the underlying contributing factors
  • Inform decision making to improve patient safety
  • Explore wider patient safety processes

The information in national learning reports is also used to inform future HSIB investigations or programmes of work.

Investigation summary

As part of our maternity investigation programme, we investigate maternal deaths of women while pregnant or within 42 days of the end of pregnancy. You can find out more about our criteria for maternal death investigations on the what we investigate page.

National learning report summary

Through our maternity investigation programme, we’ve investigated 20 maternal deaths that happened between 1 March and 31 May 2020. These deaths all happened during the COVID-19 pandemic. The women had contact with many areas of the healthcare system, including primary and secondary care, ambulance services and NHS 111.

The purpose of this national learning report is to review the findings of our maternal death investigation reports and identify any potential themes and areas of learning. This learning could potentially improve maternal care if a future surge of COVID-19 cases occurs.

Read the full report