Saving Mothers' Lives: - Public Health Agency for Northern Ireland

Of the women who were murdered:
• In all but two cases the perpetrator was a sexual partner or close family member.
• All but two of the women murdered by a partner or family member had a known history of
domestic abuse.
• The majority of the women were murdered were either late bookers or poor attenders for care,
as shown in Table 13.1.
• Many had “overbearing” partners or, as also seen in this Report, other family members who were
present at all visits.
• More than half of the women were already known to social services and nine to the local child
protection team; some had all their previous children in care.
• Three had family members or partners who were on the local sex offenders register.
• Some had histories of sexually transmitted diseases, multiple miscarriages or unexplained vaginal
bleeding in pregnancy. The reasons for this were not followed up despite the known history of abuse.
• Some were regular attenders at the Emergency Department or antenatal clinics, complaining of non
specifi c vague aches and pains.
• Four women had admissions with non specifi c abdominal pain, one women fi ve times.
• In at least three cases there was family collusion and secret keeping.
• One woman seemed to have been forced to deliver at home.
In the majority of cases clear signs and symptoms of abuse were present but they were not followed up
or acted upon:
In a widely reported case, and one of the most distressing reports ever to have been reviewed by this
Enquiry, a young mother was effectively kept prisoner, starved and assaulted by her in-laws until she
died of complications of her injuries some months after childbirth. Her autopsy report cited more than
60 recent assaults including sharp and blunt trauma, numerous broken bones and cigarette burns.
She weighed just 45 kilos, having lost 22kg in weight since giving birth a few months earlier. Nine
family members were convicted of her murder and/or perverting the course of justice.
This young woman had married into a locally “notorious” family, well known to the local police and social
services. Whilst she did manage to attend most of her antenatal visits she was always accompanied by
a member of her husband’s family. She was admitted several times for non-specifi c abdominal pains and
also failed to gain any weight after 26 weeks’ gestation. She had several episodes of vaginal discharge.
She had an unplanned “born before arrival” delivery at home and was delivered by her mother-in law. Even
though she required admission for a retained placenta, she discharged herself against medical advice and
thereafter it became increasingly diffi cult for the community midwives or health visitors to maintain contact
with her as the family became more and more obstructive.
Another woman who was obviously at very high risk also died:
This substance dependant older mother, with serious mental health problems and who had
previously been stabbed by her abusive partner, sought a termination of pregnancy too late.
She was then seen by a drug liaison midwife, who sent her for booking at a hospital clinic even
though the woman had said she would refuse to attend a hospital but would accept care provided
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