Overview
- Assistant coroner Henry Charles found a doula’s presence during a planned home labour hindered midwives’ ability to advise and provide usual care, contributing to a delayed transfer to hospital.
- Newborn Matilda Pomfret-Thomas died on 13 November 2023, aged 15 days, from neonatal hypoxic-ischemic encephalopathy after signs of fetal distress were observed during labour at home.
- Midwives noted meconium and heart-rate decelerations, an offer to transfer at 7:19am was not accepted, further meconium was seen at 10am, and the mother was not moved to hospital until 12:13pm.
- The coroner’s report urges review of doula registration, regulation and training, with notifications to the Department of Health, the Nursing and Midwifery Council, Doula UK and other bodies, and The Independent reports NICE was urged to act as well.
- Maternity and Newborn Safety Investigations cited a lack of regulation and guidance on how doulas and midwives should work together and identified 12 cases where doula conduct may have influenced poor outcomes; Doula UK says it will review and strengthen its guidance.