Confidential enquiry into maternal deaths: annual report
Analysis of 2025 data found that 54% of cases were potentially avoidable — most often because deterioration was recognised too late.
The confidential enquiry is run in cooperation with the Ministry of Health. Its purpose is to identify systemic gaps — not to assign individual blame.
Key findings
The most frequent failing was delayed recognition of critical illness, particularly in sepsis and massive haemorrhage. Early warning systems (MEOWS) were in place in only 41% of facilities.
The second recurring problem was delayed transfer: in a third of cases, moving the patient to an appropriate level of care took more than four hours.
Recommendations
The report makes three principal recommendations: mandatory MEOWS implementation in every maternity unit, quarterly massive haemorrhage drills, and a single transfer coordination centre.
