Skip to main content

Learning from maternal deaths during the COVID-19 pandemic

HSIB (Healthcare Safety Investigation Branch) have undertaken an investigation and produced a national learning report into 20 maternal deaths between…


HSIB (Healthcare Safety Investigation Branch) have undertaken an investigation and produced a national learning report into 20 maternal deaths between March and May 2020, which identified seven main themes and three safety observations. The main aim is to support the healthcare system to continue to provide safe maternity care to women and inform understanding about the range of factors that contributed to the harm. Although the focus is on maternity services and the investigation was undertaken during the pandemic, and we know that many services have improved their systems and processes since mid 2020 as they have learned and progressed, many of the issues are applicable across all services in helping to influence the development of systems and processes to optimise patient safety in the future. 

The report was a qualitative review which identified changes in practice such as access to healthcare, barriers to effective work processes and pressure for staff, some of which was widely reported in the media during the course of the pandemic, such as people delaying seeking medical advice for fear of contracting COVID-19.

The seven themes to help inform decision-making to improve patient safety

  1. Delays in accessing care: due to the demand on services during the pandemic, such as NHS 111,14 women collapsed at home of which three died and families were required to assist, impacting on family members.
  2. Delay in seeking healthcare: due to the ‘stay at home message’, risk of COVID-19 and the prospect of attending hospital without the support of their family (partner allowed when woman in labour) they put off going to hospital for longer than otherwise they may have. We have seen this widely reported across the media and patients being encouraged to attend their GP as usual to help ensure timely intervention/advice.
  3. Guidance changed rapidly: making it difficult to keep staff appraised on updates (eg updates provided 21 times between 1.3.20 -31.5.20) and what they should or should not do. For example, some trusts allowed partner/family to attend while others did not.
  4. Early warning systems to detect deterioration: NEWS 2 which is widely used across the health service was not designed for use in pregnant women, as compliance in monitoring and recording clinical observations requires an understanding of the context of the situation, such as working practices and therefore local guidance did not prompt escalation. Interestingly, there are no nationally agreed early warning systems (‘EWS’) that are maternity specific in England so it means that there is no guidance on which observations should be included or what the expected trigger thresholds for those observations should be. That said, the NHSE/I and maternity and neonatal improvement programme is working to develop a nationally agreed maternity EWS and pathway to manage maternal and neonatal deterioration (supported by HSIB).
  5. PPE: the design of work processes did not adapt to account for the time it took to put on and remove PPE, such as access and how PPE was set out, for example commencing Category 1 C-section was delayed to put on PPE. Environments were described as noisy, voices were muffled and hindered communication (for staff and patients) and staff reported heightened stress levels (so can divert attention from processing relevant information) because of communication difficulties associated with PPE. Many of these issues have been recognised across the NHS presenting challenges for staff and patients.
  6. Stress and distress: affecting performance aggravated by PPE as described above, compounded by redeployment to unfamiliar settings and difficulty in maintaining staffing levels.
  7. Difficulties in making diagnoses and choosing treatment strategies: diagnosis impeded by lack of communication and face to face assessment/access (symptoms mistakenly attributed to pregnancy and COVID-19 presented an additional challenge) and concerns about infection prevention and control (so some tests not done due to risk of transmission of the virus) along with complexity caused by rapidly acquired knowledge of a new disease and physiology in pregnancy, although again other services also have to make difficult decisions in balancing the risks and benefits for patients.

Safety observations

The report identified three safety observations aimed at DHSC/ NHSE/NHSI to undertake further work with appropriate partners to understand the increased risk of maternal death in Black, Asian and minority ethnic groups and improve communication in those groups together with developing written safety netting advice (as women were unclear about advice regarding worsening symptoms and when to seek help) for pregnant and postpartum women about COVID-19 and other common conditions.


Moving forward, the Government is already asking services to return to ‘normal business’ so arguably the issues relating to COVID-19 are resolving, albeit there is the prospect of a third wave in autumn. However, there are potentially still opportunities to continue to improve, for instance:

  • consider the patient pathway of particular groups/services;
  • improve communication (staff and patients) as we know that poor communication is a theme commonly identified in complaints/claims; and
  • consider the design of work processes as staff and services move back to providing the range of services they did before, although many aspects are likely to be changed for ever. 

Overall the themes identified act as a reminder to be alert to how a number of factors contrive together and lead to harm. It’s highly likely there will be a public inquiry looking not only into the Government’s response to the pandemic but also how the health service responded and the lessons to be taken from this. This will be some years down the line so it’s vital that Trusts reflect on reports produced by HSIB and other organisations as well as their own internal reviews and determine how best to manage a crisis similar to the one created by COVID-19. Sadly, it’s probably a case of when, not if, that happens.

As an experienced Solicitor in the Healthcare team at Weightmans along with having enjoyed a nursing career in the health service working at senior level, Alison Brennan, Associate, leads the team on governance matters along with advising, assisting and working with trusts, on such issues as patient safety, serious incident investigations and complex complaints. More broadly, she remains alert to information, such as this report, to inform, improve and learn from actual or potential adverse patient events.

Share on Twitter