But there's a vital factor missing for the tracker to work to its full potential.

We need a national strategy for learning from deaths.

There are so many different avenues out there of data that we could collect and link to really understand what went wrong.

It might not just be the day that that person passed away.

It could have been in the 12 months, in the five years, in the 20 years.

And that information is what an inquest could disclose.

But we have no current pipeline yet.

But if she had her wish and was able to get the funding she needs, what's top of her wish list?

Thirteen-year-old Martha Mills died of sepsis in 2021 in an NHS hospital after her family's repeated warnings about her worsening condition were missed.

There was a PFD issued about, um, lessons following that inquest, and one major one being that there should be the right or the ability to, um, ask for a second opinion, and that's led to a fantastic result with Martha's Rule across the country, which is, you know, saving lives every day.

Um, but we should have a system that, um, does that without the campaigning of grieving people.

The crazy thing about this is the information is there, it's just not being used.

Um, we can track responses.

Um, we can then look at trends over time to see has there been a change in the number of deaths.

But she says the government could be doing more on a much bigger scale, pointing to reforms adopted in 2000 in her native Australia.

So in Australia, they look at every inquest, whereas in England and Wales, we're only able to look at prevention of future death reports.

Here is Dr Georgia Richards.

So just before I begin, I'll just give a bit of background about how I got to be talking to you today about deaths and the preventable death trackers.

So I started my journey in Australia.

I'm originally from Queensland.

And after working in I was working in private pain clinics with a multidisciplinary team, really interested in how we could improve the evidence base around long term treatments for people with chronic pain.

I went over to abroad to the University of Oxford to do my PhD in epidemiology to look at the global, national and local use and harms of opioids.

And that is what brought me to start looking at deaths.

that we're dealing with.

Tell us some of the things that you found in your study.

Yeah, so we were interested in looking at deaths that had occurred during maternity.

So this includes during pregnancy, during childbirth and in the postpartum period of women.

And we were looking at a 10-year period of these prevention of future death reports.

And so what we really found is that repeated concerns are raised over that decade about And these were including failures to provide appropriate treatment to women, failures to escalate care, failure to recognize risk factors and provide adequate training to midwives and those who are looking after women during the maternal period.

And These repeated concerns were not acted upon after these reports are written and issued by coroners across England and Wales the past decade.

So what can happen with this if there is all this information that the coroners know? I mean, is it to try and pressure the government into taking that into account? Of course, there's so many reviews that are taking place on failings in maternity care at the moment, including deaths.

Definitely.