Coroner Issues Stark Warning Over Unregulated Doulas Following Infant's Tragic Death
A coroner has issued a powerful warning about the potential dangers of unregulated doula involvement in home births, following the heartbreaking death of a 15-day-old baby girl. The case has ignited urgent discussions about the need for clearer boundaries and regulation within maternity support services across the UK.
Tragic Case Details and Coroner's Findings
Assistant Coroner Henry Charles for Hampshire, Portsmouth and Southampton released a prevention of future deaths report after an inquest into the death of Matilda Pomfret-Thomas. The infant passed away on 13 November 2023 from neonatal hypoxic-ischaemic encephalopathy (HIE), a severe brain injury caused by oxygen deprivation during birth.
The parents had chosen to hire a doula for their planned home birth, having experienced a traumatic hospital delivery with their first child. Doulas are non-medical support workers who provide emotional and practical assistance during pregnancy and labour, but they operate without formal regulation or mandatory training requirements.
Mr Charles stated unequivocally that "the presence of the doula did negatively impact midwives being able to provide advice to the mother and usual care." This interference occurred during critical moments when medical intervention became necessary.
Missed Warning Signs and Delayed Hospital Transfer
The coroner's report reveals several alarming missed opportunities for intervention during Matilda's birth:
- Meconium (a baby's first bowel movement that can indicate distress) was detected early in labour
- Midwives noted concerning decelerations in the baby's heart rate
- An initial offer of hospital transfer at 7.19am was not accepted
- Clear signs of worsening situation at 10am were not effectively communicated
- The mother was not transferred to hospital until 12.13pm
Mr Charles emphasised that "the implications of a deteriorating situation involving decelerations against a background of the presence of meconium... was not communicated in such a way as to lead to a transfer to hospital."
Broader Concerns About Doula Regulation and Practice
The coroner highlighted significant systemic issues surrounding doula services in the UK:
- Doula UK, while the largest representative body, is not a regulatory organisation
- Many doulas operate completely outside any professional framework
- Services are increasingly offered on a paid commercial basis
- There are no mandatory training or registration requirements
The Maternity and Newborn Safety Investigations (MNSI) body identified 12 cases where doulas "worked outside of the defined boundaries of their role" and where their involvement "potentially had an influence on the poor outcome for the family."
Industry Response and Calls for Reform
A spokesperson for Doula UK responded to the coroner's findings, stating: "We take the implications of the coroner's report extremely seriously. We have policies and practices in place to protect members and the families they support... and we will be taking steps to review and strengthen our policies."
The coroner has formally sent his report to multiple organisations including the Department of Health and the Nursing and Midwifery Council, urging them to review concerns about doula registration, regulation and training standards.
This tragic case underscores the complex relationship between emotional support services and medical care during childbirth, highlighting the urgent need for clearer guidelines and potentially enhanced regulation to ensure the safety of both mothers and babies during home births.
