Coroner wants review of doulas after baby's death

A coroner has raised concerns about the role of doulas following the death of a baby.

Matilda Pomfret Thomas was 15 days old when she died in 2023 of a brain injury, known as Hypoxic-Ischaemic Encephalopathy, following a difficult birth in Hampshire.

Assistant coroner Henry Charles said the work of a doula - who are birthing assistants without medical training - had negatively impacted the effective provision of midwifery services during the birth.

He called for their roles to be reviewed in order to prevent future deaths.

Matilda's parents had wanted to have the birth at home following a previous traumatic birth experience, the inquest heard.

But during labour, midwives faced complications and offered a transfer to hospital which was not accepted.

Charles, Assistant Coroner for Hampshire, Portsmouth and Southampton, said further concerns were "not communicated in such a way as to lead to a transfer to hospital" until several hours after the first offer.

He said midwives felt the doula had negatively affected the rapport needed for effective advice and care.

The mother was ultimately transferred to Queen Alexandra Hospital in Portsmouth where Matilda was born on 29 October 2023.

She died on 15 November at Naomi House and Jacksplace Hospice in Sutton Scotney.

Charles has filed a prevention of future deaths report raising concerns about the role of the doula in the birth.

He wrote: "Signs of fetal distress developed but the mother was not immediately transferred to hospital. A difficult atmosphere had developed.

"The midwives felt access was being restricted by the doula.

"I found that she did not actively discourage midwife access but that she was seen as, in effect, a buffer by members of the midwifery team.

"The doula was following the birth plan. The doula was supporting the parents per the birth plan, and this appears to have been perceived as grounds for hope that a home birth was still possible."

He said issues of doula registration, regulation and training should be reviewed.

The coroner also noted a report into the birth by Maternity & Newborn Safety Investigations which identified 12 cases in which there was evidence doulas potentially influenced poor outcomes for families.

The Department of Health and Social Care (DHSC), the National Institute for Health and Care Excellence and the Nursing and Midwifery Council have until 6 March to respond to the report.

A DHSC spokesperson said: "Any death of a child so young is a tragedy, and our deepest sympathies are with the family of baby Matilda.

"We are committed to responding to and learning from all prevention of future deaths report and will consider this report in full before formally responding."

The BBC has contacted Doula UK for comment.

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