Recurring concern

Unreliable safety arrangements for midwifery-led home birth care

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First reported 31 Jul 2014•Latest report 30 Apr 2026

Definition

What this concern includes

Includes failures in the dedicated safety arrangements for midwifery-led or midwife-supported home birth care, including service governance, role and referral arrangements, risk assessment, eligibility and transfer criteria, requirements for midwives' home-birth competence and exposure, senior or obstetric support, and oversight of mixed or private home-birth services.

Not included

Excludes generic maternity staffing, training or governance deficiencies that are not specifically tied to midwifery-led or midwife-supported home birth care.
Excludes pregnancy and birth risk-assessment failures where home birth eligibility or home-birth care arrangements are not materially involved.
Excludes failures in hospital-based intrapartum care, postnatal care or neonatal care that do not concern the safety of a home-birth arrangement.
Excludes general maternity referral, escalation or attendance failures where the home-birth care arrangement is not the deficient process.
Excludes the occurrence or outcome of a home birth when no failure in a dedicated home-birth safety arrangement is identified.

Reports: 5
Individual concerns: 15
Date range: 2014–2026
Stated actions: 26

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care3

National Institute for Health and Care Excellence3

NHS England3

Nursing and Midwifery Council2

Manchester University NHS Foundation Trust1

Royal College of Midwives1

Royal College of Obstetricians and Gynaecologists1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

30 Apr2026
North London
Concerns raised1
1. Failure to hold a multidisciplinary risk discussion for an unsafe home birth
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Set minimum standards for safe homebirth services, including clear terminology, safety and risk assessment, multidisciplinary care planning, consent documentation, and standardised equipment.
  Stated by NHS EnglandStated planned
Respondent positions 4
1. Position
  The NHS Trust should consider support and consent matters because they concern local NHS delivery rather than requested national guidance.
  Stated by National Institute for Health and Care ExcellenceRedirects responsibility
1. Position
  Professionals must address alternative care when NICE recommendations are not followed in the specific circumstances.
  Stated by National Institute for Health and Care ExcellenceRedirects responsibility
2. Position
  Support under the Royal College of Midwives guideline falls outside NICE’s remit because NICE did not produce that guideline.
  Stated by National Institute for Health and Care ExcellenceOutside remit
3. Position
  Responsibility for the specific homebirth concerns sits with NHS England, which will issue the substantive response.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Poppy Hope LOMAS · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Poppy Hope LOMAS died in hospital on 26 October 2022, aged 7 days, after being born in poor condition following a home delivery. The report describes multiple unrecognised risk factors during the delivery and identifies concerns about consent and risk communication, multidisciplinary review, terminology used for unsafe deliveries, and the absence of a maternal pulse oximeter from the home delivery kit.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to hold a multidisciplinary risk discussion for an unsafe home birth
Wider context from the report
“It is a matter of concern that where the patient has chosen to have an unsafe birth at home consideration is not given to holding a Multi-Disciplinary Team Meeting with the consultant obstetrician, hospital midwives & community midwives and the patient, to ensure that the patient receives an understanding of the risks to the baby and to themselves.. ”
Source location
Poppy Hope LOMAS · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Set minimum standards for safe homebirth services, including clear terminology, safety and risk assessment, multidisciplinary care planning, consent documentation, and standardised equipment.

Verbatim wording from the response
“By autumn 2026, we anticipate setting out the minimum standards that providers and commissioners of maternity services will be expected to meet to support the delivery of a safe, effective, equitable and personalised home birth service. The standards will include the use of appropriate and clear language in discussing women’s preferences, including review of the term “Out of Guidance”. The standards will also include detail on the assessment of safety and risk required, and the need for multi-disciplinary team working in the formulation of care plans and their documentation. This will also include consideration of the use of consent forms which are not currently used in maternity services for any place of birth. It will also include reference to the standardised equipment required for clinical care provided during homebirth.”

Source location
Response from NHS England
Page 2 · response
Published 10 July 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The NHS Trust should consider support and consent matters because they concern local NHS delivery rather than requested national guidance.

Verbatim wording from the response
“Matters 2 and 3”

Source location
Response from National Institute for Health and Care Excellence
Page 2 · response
Published 10 July 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Professionals must address alternative care when NICE recommendations are not followed in the specific circumstances.

Verbatim wording from the response
“We have considered the information provided in the report, and would comment that it should be standard practice, if a patient decides not to follow advice given, that the healthcare professional should document the discussion, any professional concerns and care planned that is acceptable to the patient. NICE cannot give recommendations on alternative care where our recommendations are not followed; this would need to be addressed by the professional in the specific circumstances.”

Source location
Response from National Institute for Health and Care Excellence
Page 3 · response
Published 10 July 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Support under the Royal College of Midwives guideline falls outside NICE’s remit because NICE did not produce that guideline.

Verbatim wording from the response
“The support that the NHS trust can provide to the patient in these circumstances is covered in the Royal College of Midwives guideline Care Outside Guidance.”

Source location
Response from National Institute for Health and Care Excellence
Page 3 · response
Published 10 July 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Responsibility for the specific homebirth concerns sits with NHS England, which will issue the substantive response.

Verbatim wording from the response
“In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns, and I understand there is work underway to develop national standards and a clear framework for homebirth services. As responsibility for the specific matters of concern you have raised sits with NHS England, they will be issuing a substantive response addressing each of these concerns.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 10 July 2026
Open published response
27 Jan2026
Cheshire
Concerns raised6
1. Lack of guidance on the threshold for transfer from home birth to hospital
2. Lack of guidance on midwife training for competent home birth management
3. Lack of guidance on midwife experience requirements for home birth management
1. Lack of guidance on backup arrangements for electronic system failure during home births
2. Lack of guidance on safe home birth staffing and equipment levels
3. Lack of national guidance on the home birth model of care
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Maintain national intrapartum-care guidance covering home-birth eligibility, informed choice, observations, and thresholds for transfer to obstetric-led care.
  Stated by National Institute for Health and Care ExcellenceStated completed
2. Action
  Write to NHS maternity providers urging urgent review of homebirth service safety and quality.
  Stated by NHS EnglandStated completed
3. Action
  Develop national resources with partner organisations to address gaps in homebirth guidance and safety practice.
  Stated by NHS EnglandStated in progress
1. Action
  Work with the NMC to consider post-registration standards specifically focused on homebirths.
  Stated by NHS EnglandStated planned
2. Action
  Work with other organisations to ensure multidisciplinary emergency simulation includes a scenario beginning in a community or homebirth setting.
  Stated by NHS EnglandStated planned
3. Action
  Maintain national safe-midwifery-staffing guidance covering staffing establishments, skill mix, staffing assessment, and monitoring across home and community maternity settings.
  Stated by National Institute for Health and Care ExcellenceStated completed
Respondent positions 9
1. Position
  NHS England holds operational responsibility for homebirth guidance, data collection and training, and will address these concerns.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  Current NICE guidance appropriately covers home birth risks, eligibility, informed choice, midwife support and transfer considerations.
  Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficient
2. Position
  NICE disputes that no guidance exists on thresholds for transferring women from home birth to obstetric-led care.
  Stated by National Institute for Health and Care ExcellenceDisputes the concern
3. Position
  Training and competency requirements for midwives are outside NICE’s remit.
  Stated by National Institute for Health and Care ExcellenceOutside remit
4. Position
  Midwife training and competency requirements should be addressed by the NMC and NHS England’s relevant workforce and education directorate.
  Stated by National Institute for Health and Care ExcellenceRedirects responsibility
5. Position
  Information about the required experience of midwifery teams supporting home births is outside NICE’s role.
  Stated by National Institute for Health and Care ExcellenceOutside remit
6. Position
  The NMC and Royal College of Midwives should consider required experience standards for midwifery teams supporting home births.
  Stated by National Institute for Health and Care ExcellenceRedirects responsibility
7. Position
  Responsibility for backup systems when electronic systems fail rests with NHS care commissioning bodies, particularly NHS England.
  Stated by National Institute for Health and Care ExcellenceRedirects responsibility
8. Position
  Existing NICE safe midwifery staffing guidance covers home and community settings, including staffing levels, establishment and skill mix.
  Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficient
AI-generated summary

Pippa Isobel Waller GILLIBRAND · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Pippa Isobel Waller Gillibrand was delivered by forceps in poor condition after a home birth was continued despite staffing, equipment and fetal heart-rate monitoring issues, and she later died in hospital from a severe irreversible brain injury. The report identified concerns about the lack of guidance on home-birth staffing, midwife competence, transfer thresholds, equipment, supervision, electronic-recording failures and information for parents, as well as the absence of national or local home-birth outcome data.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of guidance on the threshold for transfer from home birth to hospital
Wider context from the report
“1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on: a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency. b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills. c. The threshold for transfer to hospital. d. Safe staffing and equipment levels, without which the service should be suspended. e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes. f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine. g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice. 2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth. ”
Source location
Pippa Isobel Waller GILLIBRAND · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of guidance on midwife training for competent home birth management
Wider context from the report
“1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on: a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency. b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills. c. The threshold for transfer to hospital. d. Safe staffing and equipment levels, without which the service should be suspended. e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes. f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine. g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice. 2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth. ”
Source location
Pippa Isobel Waller GILLIBRAND · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of guidance on midwife experience requirements for home birth management
Wider context from the report
“1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on: a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency. b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills. c. The threshold for transfer to hospital. d. Safe staffing and equipment levels, without which the service should be suspended. e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes. f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine. g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice. 2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth. ”
Source location
Pippa Isobel Waller GILLIBRAND · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of guidance on backup arrangements for electronic system failure during home births
Wider context from the report
“1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on: a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency. b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills. c. The threshold for transfer to hospital. d. Safe staffing and equipment levels, without which the service should be suspended. e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes. f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine. g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice. 2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth. ”
Source location
Pippa Isobel Waller GILLIBRAND · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of guidance on safe home birth staffing and equipment levels
Wider context from the report
“1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on: a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency. b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills. c. The threshold for transfer to hospital. d. Safe staffing and equipment levels, without which the service should be suspended. e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes. f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine. g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice. 2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth. ”
Source location
Pippa Isobel Waller GILLIBRAND · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of national guidance on the home birth model of care
Wider context from the report
“1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on: a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency. b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills. c. The threshold for transfer to hospital. d. Safe staffing and equipment levels, without which the service should be suspended. e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes. f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine. g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice. 2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth. ”
Source location
Pippa Isobel Waller GILLIBRAND · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Maintain national intrapartum-care guidance covering home-birth eligibility, informed choice, observations, and thresholds for transfer to obstetric-led care.

Verbatim wording from the response
“Home birth is covered in NICE’s guideline on intrapartum care (NG235). The risks and benefits of home birth compared to birth in an alongside midwifery unit, freestanding midwifery unit and hospital are covered, with information for counselling detailed in tables 6 to 9. The guideline provides comprehensive guidance on intrapartum care, including (but not limited to) home births. The guideline covers:”

Source location
2026-0042 - Response from NICE
Page 1 · response
Published 29 January 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Write to NHS maternity providers urging urgent review of homebirth service safety and quality.

Verbatim wording from the response
“On 26 November 2025, NHS England wrote to all NHS maternity providers in England asking them to urgently review the safety and quality of their homebirth services. In particular, we urged them to consider the following issues:”

Source location
2026-0042 - Response from NHS England
Page 1 · response
Published 29 January 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop national resources with partner organisations to address gaps in homebirth guidance and safety practice.

Verbatim wording from the response
“We acknowledge that the current intrapartum care guidance does not provide sufficient clarity to women, staff and services as to how to safely support requests for and the provision of homebirth services. NHS England will continue working with partners including NICE, the Royal College of Midwives, the Royal College of Obstetrics and Gynaecology, the Nursing & Midwifery Council, Maternity & Newborn Safety Investigations, the Care Quality Commission, and the General Medical Council to develop further resources that enable services to consistently support commissioners, providers and women and families.”

Source location
2026-0042 - Response from NHS England
Page 2 · response
Published 29 January 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with the NMC to consider post-registration standards specifically focused on homebirths.

Verbatim wording from the response
“The NMC also maintains standards of proficiency for all midwives, which represent the skills, knowledge and attributes they must demonstrate. While the number of births attended is not alone a reliable indicator of a midwife’s fitness to practice intrapartum care, we will work with the NMC to consider the requirements for post-registration standards, that have a specific focus on homebirths, as part of the development of resources mentioned above.”

Source location
2026-0042 - Response from NHS England
Page 3 · response
Published 29 January 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with other organisations to ensure multidisciplinary emergency simulation includes a scenario beginning in a community or homebirth setting.

Verbatim wording from the response
“Midwives providing care at home must be able to respond to developing emergencies on their own, sometimes without the support of multi-disciplinary teams and immediate access to hospital facilities, until additional assistance is provided from the ambulance service. Such midwives are expected to undergo regular training in this. NHS England will work with other organisations to ensure that multi-disciplinary team training simulation for obstetric emergencies includes at least one scenario starting in a community/homebirth setting, in addition to the yearly training competency required by all NHS midwives within the NHS England » Core competency framework version two (2023).”

Source location
2026-0042 - Response from NHS England
Page 3 · response
Published 29 January 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Maintain national safe-midwifery-staffing guidance covering staffing establishments, skill mix, staffing assessment, and monitoring across home and community maternity settings.

Verbatim wording from the response
“NICE’s guideline on safe midwifery staffing for maternity settings (NG4) covers safe midwifery staffing in all maternity settings, including at home and in the community.”

Source location
2026-0042 - Response from NICE
Page 3 · response
Published 29 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS England holds operational responsibility for homebirth guidance, data collection and training, and will address these concerns.

Verbatim wording from the response
“You raise concerns over the lack of national guidance for home births, particularly the model of care, as well as concerns that there is no national or local collection of data around home births. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns, and I understand there is work underway to develop national standards and a clear framework for homebirth services. As operational responsibility for issuing guidance and collecting data around home births sits with NHS England, they will be issuing a substantive response addressing the specific matters of concern raised.”

Source location
2026-0042 - Response from DHSC
Page 1 · response
Published 29 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Current NICE guidance appropriately covers home birth risks, eligibility, informed choice, midwife support and transfer considerations.

Verbatim wording from the response
“Within the guideline, medical conditions and other factors that may affect the choice of planned place of birth are not given as contraindications to home birth but indicate where care in an obstetric unit would be expected to reduce risk to the mother or the baby. There are also recommendations that support further discussion with an appropriately trained senior or consultant midwife and/or a senior or consultant obstetrician (if there are obstetric issues) if such a discussion is wanted by the midwife or the woman. See recommendations 1.3.9 to 1.3.11 and tables 6 to 9.”

Source location
2026-0042 - Response from NICE
Page 2 · response
Published 29 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NICE disputes that no guidance exists on thresholds for transferring women from home birth to obstetric-led care.

Verbatim wording from the response
“c. There is no guidance on the threshold for transfer to hospital from a home birth.”

Source location
2026-0042 - Response from NICE
Page 2 · response
Published 29 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Training and competency requirements for midwives are outside NICE’s remit.

Verbatim wording from the response
“a. There is no guidance on the training that a midwife should undergo to ensure they are competent to manage a home birth”

Source location
2026-0042 - Response from NICE
Page 2 · response
Published 29 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Midwife training and competency requirements should be addressed by the NMC and NHS England’s relevant workforce and education directorate.

Verbatim wording from the response
“Training of midwives and the attainment and assessment of competencies are not within NICE’s remit. I recommend that you address these concerns to the organisations responsible for training and regulation of midwives (such as the Nursing and Midwifery Council (NMC) and NHS England’s Workforce, Training and Education Directorate).”

Source location
2026-0042 - Response from NICE
Page 2 · response
Published 29 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Information about the required experience of midwifery teams supporting home births is outside NICE’s role.

Verbatim wording from the response
“It is, however, true that NICE does not provide information on the required experience of the midwifery team for supporting home births, but this is outside our role. This is an issue for the NMC and the RCM to consider.”

Source location
2026-0042 - Response from NICE
Page 4 · response
Published 29 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The NMC and Royal College of Midwives should consider required experience standards for midwifery teams supporting home births.

Verbatim wording from the response
“It is, however, true that NICE does not provide information on the required experience of the midwifery team for supporting home births, but this is outside our role. This is an issue for the NMC and the RCM to consider.”

Source location
2026-0042 - Response from NICE
Page 4 · response
Published 29 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Responsibility for backup systems when electronic systems fail rests with NHS care commissioning bodies, particularly NHS England.

Verbatim wording from the response
“f. There is no system for back-up should electronic systems fail”

Source location
2026-0042 - Response from NICE
Page 3 · response
Published 29 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing NICE safe midwifery staffing guidance covers home and community settings, including staffing levels, establishment and skill mix.

Verbatim wording from the response
“d. There is no guidance on safe staffing and equipment levels for home birth”

Source location
2026-0042 - Response from NICE
Page 3 · response
Published 29 January 2026
Open published response
5 Nov2025
Manchester North
Concerns raised6
1. Unavailability or significant delay of required interventions during high-risk home births
2. Lack of national data collection on home birth transfers, outcomes and out-of-guidance care
3. Inconsistent models of home birth care
1. Lack of a national framework for safe home birth eligibility and midwifery practice
2. Lack of national guidance on staffing, training and experience for home birth midwives
3. Lack of bespoke training needs analysis for home birth team midwives
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 16
1. Action
  Approve funding for a neonatal resuscitation training programme covering clinicians’ roles and out-of-hospital homebirth scenarios.
  Stated by Department of Health and Social CareStated completed
2. Action
  Ask all NHS maternity providers to urgently review the safety and quality of their homebirth services.
  Stated by NHS EnglandStated completed
3. Action
  Remind maternity providers of expectations for homebirth operating procedures and high-risk homebirth pathways, with escalation through the Perinatal Quality Oversight Model.
  Stated by NHS EnglandStated completed
1. Action
  Ensure multidisciplinary training for obstetric emergencies includes a scenario beginning in a community or homebirth setting.
  Stated by NHS EnglandStated planned
2. Action
  Provide the out-of-hospital Neonatal Life Support course, including homebirth scenarios, to NHS trusts.
  Stated by NHS EnglandStated completed
3. Action
  Support NICE’s ongoing work to develop evidence-based guidance covering maternity care, including home-birth-relevant aspects.
  Stated by Royal College of Obstetricians and GynaecologistsStated planned
4. Action
  Develop a Good Practice Paper on supporting women requesting care outside guidance, including obstetricians’ roles within the wider team.
  Stated by Royal College of Obstetricians and GynaecologistsStated in progress
5. Action
  Work with the UK Midwifery Study System to develop national data on transfers from home to hospital and maternal and neonatal outcomes.
  Stated by NHS EnglandStated planned
6. Action
  Participate in the joint safety stakeholder work that developed a task and finish group for national homebirth pathways.
  Stated by Nursing and Midwifery CouncilStated completed
7. Action
  Contribute to the task and finish group on national homebirth guidance, frameworks, ethical proportionality, informed risk discussions, maternal risks, terminology and training needs.
  Stated by Nursing and Midwifery CouncilStated planned
8. Action
  Develop national resources with partner organisations to clarify safe homebirth support, including responses to high-risk requests and variation in service models.
  Stated by NHS EnglandStated in progress
9. Action
  Engage with NHS England, regulators and arm’s-length bodies to support development of a national standardised home birth policy.
  Stated by Royal College of MidwivesStated completed
10. Action
  Clarify with partners whether maternity professionals may withdraw services when homebirth or requested care is considered highly unsafe or unreasonable.
  Stated by NHS EnglandStated in progress
11. Action
  Join Nursing and Midwifery Council discussions on post-registration standards for midwives.
  Stated by Department of Health and Social CareStated planned
12. Action
  Work with the Nursing and Midwifery Council to consider post-registration standards specifically focused on homebirths.
  Stated by NHS EnglandStated planned
13. Action
  Advocate for protected, funded continuing professional development time and role-specific workforce development for home birth care.
  Stated by Royal College of MidwivesStated in progress
Respondent positions 17
1. Position
  Current NICE intrapartum guidance appropriately covers home births, and insufficient evidence justifies changing its recommendations.
  Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficient
1. Position
  NHS England is responsible for leading national home-birth policy and ensuring providers implement it consistently.
  Stated by Royal College of MidwivesRedirects responsibility
2. Position
  Ambulance provision and emergency-transfer accessibility protocols are outside the respondent’s remit.
  Stated by Royal College of MidwivesOutside remit
3. Position
  No action can be taken on national clinical data collection because the organisation neither holds nor mandates such data.
  Stated by Nursing and Midwifery CouncilUnable to act
4. Position
  Some national homebirth data already exists, although it does not capture transfers or maternal and neonatal outcomes.
  Stated by NHS EnglandDisputes the concern
5. Position
  NHSE and DHSC are best positioned to address the lack of national data on home birth transfers, outcomes and care outside guidance.
  Stated by Royal College of Obstetricians and GynaecologistsRedirects responsibility
6. Position
  NHS England is responsible for national data collection and record keeping concerning home-birth outcomes and transfers.
  Stated by Royal College of MidwivesRedirects responsibility
7. Position
  RCOG advice, potentially through a practice paper and consent document, would be the appropriate response to the requested national guidance.
  Stated by National Institute for Health and Care ExcellenceRedirects responsibility
8. Position
  Points 7–9 fall outside NICE’s role and therefore are not addressed by NICE.
  Stated by National Institute for Health and Care ExcellenceOutside remit
9. Position
  It is not possible to define every high-risk home-birth scenario because suitability depends on local and individual factors, including transfer capacity.
  Stated by National Institute for Health and Care ExcellenceUnable to act
10. Position
  Workforce modelling for staffing, training and experience in home birth care is outside the regulator’s functions.
  Stated by Nursing and Midwifery CouncilOutside remit
11. Position
  Midwives and their employers are responsible for ensuring the skills, knowledge and capabilities needed to provide care.
  Stated by Nursing and Midwifery CouncilRedirects responsibility
12. Position
  Training midwives is outside NICE’s responsibility.
  Stated by National Institute for Health and Care ExcellenceOutside remit
13. Position
  Midwife training is better addressed by the NMC, RCM and educational bodies providing training.
  Stated by National Institute for Health and Care ExcellenceRedirects responsibility
14. Position
  The RCM and NMC are best positioned to address national guidance on staffing, training and experience for midwives providing home birth care.
  Stated by Royal College of Obstetricians and GynaecologistsRedirects responsibility
15. Position
  NHS England and the Nursing and Midwifery Council are responsible for mandatory training and revalidation standards.
  Stated by Royal College of MidwivesRedirects responsibility
16. Position
  The RCM and NMC are best positioned to address training needs analysis for midwives practising in home birth teams.
  Stated by Royal College of Obstetricians and GynaecologistsRedirects responsibility
AI-generated summary

Jennifer Cahill and Agnes Cahill · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jennifer Cahill died in hospital on 4 June 2024 after post-partum haemorrhage, a fourth-degree perineal tear and cardiac arrest following a home birth. Her daughter, Agnes Cahill, was born on 2 June 2024, required resuscitation after complications during birth, and died in neonatal intensive care on 7 June 2024. The report identified concerns including failures in antenatal planning, fetal monitoring, resuscitation and post-birth care, as well as the absence of national guidance and a robust framework for supporting higher-risk home births.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability or significant delay of required interventions during high-risk home births
Wider context from the report
“2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where required interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care. There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting. ”
Source location
Jennifer Cahill and Agnes Cahill · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of national data collection on home birth transfers, outcomes and out-of-guidance care
Wider context from the report
“9. The lack of national data collection means there is no data to evidence the number of women who are transferred in during labour or after birth, maternal or neonatal outcomes, number of women who are considered out of guidance. ”
Source location
Jennifer Cahill and Agnes Cahill · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inconsistent models of home birth care
Wider context from the report
“3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service. There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework. ”
Source location
Jennifer Cahill and Agnes Cahill · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a national framework for safe home birth eligibility and midwifery practice
Wider context from the report
“2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where required interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care. There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting. ”
Source location
Jennifer Cahill and Agnes Cahill · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of national guidance on staffing, training and experience for home birth midwives
Wider context from the report
“10. The no national guidance on the model of staffing, training and experience for midwives providing home birth care. ”
Source location
Jennifer Cahill and Agnes Cahill · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of bespoke training needs analysis for home birth team midwives
Wider context from the report
“8. No bespoke training needs analysis has been conducted focusing on midwives practicing in home birth teams. ”
Source location
Jennifer Cahill and Agnes Cahill · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Approve funding for a neonatal resuscitation training programme covering clinicians’ roles and out-of-hospital homebirth scenarios.

Verbatim wording from the response
“Last year, the Department of Health and Social Care approved funding for a new neonatal resuscitation training programme. This training will be specific to the roles and responsibilities for clinicians and the out of hospital course includes homebirth scenarios. Whilst NHS England commissioned the Resuscitation Council UK to update their Neonatal Life Support course, the out of hospital course is now available to staff in all Trusts.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Ask all NHS maternity providers to urgently review the safety and quality of their homebirth services.

Verbatim wording from the response
“On 26 November 2025, NHS England wrote to all NHS maternity providers in England asking them to urgently review the safety and quality of their homebirth services. In particular, we have urged them to consider the following issues which were highlighted in your Report:”

Source location
Response from NHS England
Page 1 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Remind maternity providers of expectations for homebirth operating procedures and high-risk homebirth pathways, with escalation through the Perinatal Quality Oversight Model.

Verbatim wording from the response
“We already expect maternity provider Trusts to have operating procedures for planning births at home and pathways for women with high-risk pregnancies requesting home births. We have written to all maternity providers reminding them of those expectations and action to be taken. As a way to escalate where Trusts may not have appropriate operating procedures for planning births at home and managing high-risk pregnancies, the Perinatal Quality Oversight Model (2025) provides a structured approach for identifying and responding to safety concerns across Trusts, Integrated Care Boards (ICBs), and neonatal operational delivery networks.”

Source location
Response from NHS England
Page 3 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Ensure multidisciplinary training for obstetric emergencies includes a scenario beginning in a community or homebirth setting.

Verbatim wording from the response
“Midwives practicing in homebirth settings require the same level of skills, knowledge and proficiencies and provide the same clinical care as midwives in other settings. However, midwives providing care at home must be able to respond to developing emergencies in these specific settings, sometimes without the support of multi-disciplinary teams and immediate access to hospital facilities and are expected to undergo regular training in this. We will work with other organisations to ensure that multi-disciplinary team training for obstetric emergencies includes at least one scenario starting in a community/homebirth setting.”

Source location
Response from NHS England
Page 4 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide the out-of-hospital Neonatal Life Support course, including homebirth scenarios, to NHS trusts.

Verbatim wording from the response
“NHS England has also commissioned the Resuscitation Council UK (RSUK) to design an updated Neonatal Life Support (NLS) course, specific to roles and responsibilities for clinicians, including the out-of-hospital course. Training is available for multi-disciplinary teams, including ambulance crews. Funding is being provided for 6,000 practitioners to have NLS training over a 2-year period. The course build remains to be completed. However, the out-of-hospital course is now available to Trusts and includes homebirth scenarios.”

Source location
Response from NHS England
Page 4 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Support NICE’s ongoing work to develop evidence-based guidance covering maternity care, including home-birth-relevant aspects.

Verbatim wording from the response
“in an obstetric led unit. This guideline covers the general principles of care for women in all birth settings. The guideline provides advice regarding fetal monitoring in labour which is relevant to birth at home as well as in hospital settings, and links to the NICE Guideline on fetal monitoring in labour (2022)². The guideline also provides advice on care of the perineum to minimise the chance of perineal trauma as well as advice on the management of the third stage of labour (including “active management” of the third stage), initial assessment and management of post-partum haemorrhage and when to consider transfer to obstetric care) which is relevant to birth in any setting. Lastly the guideline covers resuscitation of the newborn including the training required for healthcare professionals, the need for emergency referral pathways and facilities for transfer.”

Source location
Response from Royal College of Obstetricians & Gynaecologists
Page 2 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a Good Practice Paper on supporting women requesting care outside guidance, including obstetricians’ roles within the wider team.

Verbatim wording from the response
“2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where known interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care. There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting.”

Source location
Response from Royal College of Obstetricians & Gynaecologists
Page 2 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with the UK Midwifery Study System to develop national data on transfers from home to hospital and maternal and neonatal outcomes.

Verbatim wording from the response
“With regard to national data, some is already available. Data drawn from the MBRACE 2009 to 2024 reports, by Professor Marian Knight, Director of the National Perinatal Epidemiology Unit, highlights that over 15 years, there have been 19 women who died who planned to give birth at home, amongst 11.5 million women giving birth and that, of those 19 women, 6 actually gave birth at home. We acknowledge that this does not provide evidence of the number of women who have been transferred from home to hospital during labour or after birth, or of their and their baby’s outcomes. We will work with the UK Midwifery Study System (UKMIDSS) to develop a solution to this.”

Source location
Response from NHS England
Page 4 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Participate in the joint safety stakeholder work that developed a task and finish group for national homebirth pathways.

Verbatim wording from the response
“On 8 December, we participated in a joint safety stakeholder meeting to discuss the specific matters of concerns identified. This meeting was attended by senior maternity and neonatal leaders from NHS England, Maternity and Neonatal transformation programme at NHS England, the Royal College of Midwives (RCM), NHS Resolution (NHSR), the National Institute for Health and Care Excellence (NICE), the General Medical Council, Maternity and Neonatal Safety Investigations”

Source location
Response from Nursing & Midwifery Council
Page 3 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Contribute to the task and finish group on national homebirth guidance, frameworks, ethical proportionality, informed risk discussions, maternal risks, terminology and training needs.

Verbatim wording from the response
“As the professional regulator for midwives in the UK, the NMC plans to play an active role in the group in line with our regulatory role. More specifically, we propose to take the following actions in response to the matters of concern detailed in your report as follows:”

Source location
Response from Nursing & Midwifery Council
Page 4 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop national resources with partner organisations to clarify safe homebirth support, including responses to high-risk requests and variation in service models.

Verbatim wording from the response
“We acknowledge that the current intrapartum care guidance does not provide sufficient clarity to women, staff and services as to how to safely support requests for and the provision of homebirth services. NHS England will work with partners including NICE, the Royal College of Midwives, the Royal College of Obstetrics and Gynaecology, the Nursing & Midwifery Council, Maternity & Newborn Safety Investigations, the Care Quality Commission, and the General Medical Council to develop further resources that enable services to consistently support commissioners, providers and women and families.”

Source location
Response from NHS England
Page 2 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Engage with NHS England, regulators and arm’s-length bodies to support development of a national standardised home birth policy.

Verbatim wording from the response
“• The RCM has engaged actively with NHS England, regulators, and arm’s length bodies, including in the joint meeting on 8 December 2025, where the need for a national standardised policy on home birth services was formally recognised. NHS England has agreed to lead this work, with the RCM as a key stakeholder.”

Source location
Response from Royal College of Midwives
Page 2 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Clarify with partners whether maternity professionals may withdraw services when homebirth or requested care is considered highly unsafe or unreasonable.

Verbatim wording from the response
“addition, some women who cannot be supported to birth at home due to the level of risk may choose to give birth unassisted, which carries a higher risk. We will build on work already started, looking to clarify whether NHS health professionals providing maternity services may withdraw midwifery services from women birthing at home against professional advice and/or from women making requests with regards to care/treatment that are considered highly unsafe or unreasonable.”

Source location
Response from NHS England
Page 3 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Join Nursing and Midwifery Council discussions on post-registration standards for midwives.

Verbatim wording from the response
“You raised matters relating to the proficiency, training and skills of midwives in homebirths. The Nursing and Midwifery Council are responsible for setting the proficiencies midwives need to practice, ensuring they have the right skills, knowledge and expertise to safely support women and babies. They are mapping these proficiencies against previous maternity reviews and investigations to better understand where standards need to be strengthened. The Department welcomes, and will join, discussions with the Nursing Midwifery Council relating to post registration standards, whilst noting that the number of deliveries is not alone, a reliable criterion for assessing a midwife’s overall fitness to practice.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with the Nursing and Midwifery Council to consider post-registration standards specifically focused on homebirths.

Verbatim wording from the response
“The NMC also maintains standards of proficiency for all midwives, which represent the skills, knowledge and attributes they must demonstrate. While the number of births attended is not alone a reliable indicator of a midwife’s fitness to practise, we will work with the NMC to consider the requirements for post-registration standards, that have a specific focus on homebirths, as part of the development of resources mentioned above.”

Source location
Response from NHS England
Page 3 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Advocate for protected, funded continuing professional development time and role-specific workforce development for home birth care.

Verbatim wording from the response
“• The RCM has consistently highlighted the need for role-specific training and professional support in discussions with NHS partners. We advocate for protected, funded time for CPD. In line with other UK countries, such as Wales, the RCM calls on the government in England to ringfence hours of protected CPD annually for midwives, ensuring that all staff have sufficient opportunity to maintain skills and develop specialist expertise.”

Source location
Response from Royal College of Midwives
Page 6 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Current NICE intrapartum guidance appropriately covers home births, and insufficient evidence justifies changing its recommendations.

Verbatim wording from the response
“Intrapartum care (NG235) covers assessment in the first stage of labour in any setting, including the observations of the mother and the unborn baby that should lead to the transfer of the woman to obstetric-led care, noting also that multiple risk factors may increase the urgency of the transfer, particularly if they have a cumulative effect. The guideline notes the more frequent observations of the mother and the unborn baby that should be undertaken in the second stage.”

Source location
Response from National Institute for Health and Care Excellence
Page 2 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS England is responsible for leading national home-birth policy and ensuring providers implement it consistently.

Verbatim wording from the response
“• The RCM has engaged actively with NHS England, regulators, and arm’s length bodies, including in the joint meeting on 8 December 2025, where the need for a national standardised policy on home birth services was formally recognised. NHS England has agreed to lead this work, with the RCM as a key stakeholder.”

Source location
Response from Royal College of Midwives
Page 2 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Ambulance provision and emergency-transfer accessibility protocols are outside the respondent’s remit.

Verbatim wording from the response
“• Whilst not the remit of the RCM and the direct issue raised in the PFD Report, the provision of ambulance services and protocols to support accessibility of this service to women should they need an emergency transfer during labour and birth needs further consideration.”

Source location
Response from Royal College of Midwives
Page 4 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
No action can be taken on national clinical data collection because the organisation neither holds nor mandates such data.

Verbatim wording from the response
“9. The lack of national data collection means there is no data to evidence the number of women who are transferred in during labour or after birth, maternal or neonatal outcomes, number of women who are considered out of guidance.”

Source location
Response from Nursing & Midwifery Council
Page 6 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Some national homebirth data already exists, although it does not capture transfers or maternal and neonatal outcomes.

Verbatim wording from the response
“With regard to national data, some is already available. Data drawn from the MBRACE 2009 to 2024 reports, by Professor Marian Knight, Director of the National Perinatal Epidemiology Unit, highlights that over 15 years, there have been 19 women who died who planned to give birth at home, amongst 11.5 million women giving birth and that, of those 19 women, 6 actually gave birth at home. We acknowledge that this does not provide evidence of the number of women who have been transferred from home to hospital during labour or after birth, or of their and their baby’s outcomes. We will work with the UK Midwifery Study System (UKMIDSS) to develop a solution to this.”

Source location
Response from NHS England
Page 4 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHSE and DHSC are best positioned to address the lack of national data on home birth transfers, outcomes and care outside guidance.

Verbatim wording from the response
“9. The lack of national data collection means there is no data to evidence the number of women who are transferred in during labour or after birth, maternal or neonatal outcomes, number of women who are considered out of guidance.”

Source location
Response from Royal College of Obstetricians & Gynaecologists
Page 4 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS England is responsible for national data collection and record keeping concerning home-birth outcomes and transfers.

Verbatim wording from the response
“9. The lack of national data collection means there is no data to evidence the number of women who are transferred in during labour or after birth, maternal or neonatal outcomes, number of women who are considered out of guidance.”

Source location
Response from Royal College of Midwives
Page 6 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
RCOG advice, potentially through a practice paper and consent document, would be the appropriate response to the requested national guidance.

Verbatim wording from the response
“There is no national guidance to support women or their care providers in this setting. We would suggest that advice from the Royal College of Obstetricians and Gynaecologists (RCOG) would be most appropriate to address this point, perhaps in a practice paper with a consent advice document.”

Source location
Response from National Institute for Health and Care Excellence
Page 2 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Points 7–9 fall outside NICE’s role and therefore are not addressed by NICE.

Verbatim wording from the response
“Points 7-9 do not relate to the role of NICE.”

Source location
Response from National Institute for Health and Care Excellence
Page 4 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
It is not possible to define every high-risk home-birth scenario because suitability depends on local and individual factors, including transfer capacity.

Verbatim wording from the response
“It is not possible for us to list all the potential scenarios that might occur, nor to define what is ‘too high risk’ as this will depend upon many local and individual factors. Local transfer times, staffing, and the ability to escalate care quickly are key determinants of whether planned home birth is appropriate for an individual.”

Source location
Response from National Institute for Health and Care Excellence
Page 2 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Workforce modelling for staffing, training and experience in home birth care is outside the regulator’s functions.

Verbatim wording from the response
“10. There is no national guidance on the model of staffing, training and experience for midwives providing home birth care.”

Source location
Response from Nursing & Midwifery Council
Page 6 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Midwives and their employers are responsible for ensuring the skills, knowledge and capabilities needed to provide care.

Verbatim wording from the response
“As the regulator of midwives, we do not contribute to workforce modelling. However, our standards are clear regarding our expectations that midwives should be able to care for women in all birth settings. Midwives, with support from their employers are responsible for ensuring they have the skills, knowledge and capabilities to provide care.”

Source location
Response from Nursing & Midwifery Council
Page 6 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Training midwives is outside NICE’s responsibility.

Verbatim wording from the response
“Training of midwives is not the responsibility of NICE and is better addressed by the Nursing and Midwifery Council (NMC), Royal College of Midwives (RCM) and educational bodies who provide such training.”

Source location
Response from National Institute for Health and Care Excellence
Page 4 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Midwife training is better addressed by the NMC, RCM and educational bodies providing training.

Verbatim wording from the response
“Training of midwives is not the responsibility of NICE and is better addressed by the Nursing and Midwifery Council (NMC), Royal College of Midwives (RCM) and educational bodies who provide such training.”

Source location
Response from National Institute for Health and Care Excellence
Page 4 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The RCM and NMC are best positioned to address national guidance on staffing, training and experience for midwives providing home birth care.

Verbatim wording from the response
“10. There is no national guidance on the model of staffing, training and experience for midwives providing home birth care.”

Source location
Response from Royal College of Obstetricians & Gynaecologists
Page 4 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS England and the Nursing and Midwifery Council are responsible for mandatory training and revalidation standards.

Verbatim wording from the response
“• The RCM has consistently highlighted the need for role-specific training and professional support in discussions with NHS partners. We advocate for protected, funded time for CPD. In line with other UK countries, such as Wales, the RCM calls on the government in England to ringfence hours of protected CPD annually for midwives, ensuring that all staff have sufficient opportunity to maintain skills and develop specialist expertise.”

Source location
Response from Royal College of Midwives
Page 6 · response
Published 7 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The RCM and NMC are best positioned to address training needs analysis for midwives practising in home birth teams.

Verbatim wording from the response
“8. No bespoke training needs analysis has been conducted focusing on midwives practising in home birth teams.”

Source location
Response from Royal College of Obstetricians & Gynaecologists
Page 3 · response
Published 7 November 2025
Open published response
19 May2023
Warwickshire
Concerns raised1
1. Lack of specific requirements for midwives’ training and ongoing exposure to home births
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Emilia Watson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Emilia Watson was delivered by Caesarean section on 5 April 2021 after concerns about fetal wellbeing and fetal heart rate; she died shortly after birth despite resuscitation attempts. The report raised concerns about the limited home-birth experience of the two attending midwives and the lack of specific regulatory requirements for training or ongoing exposure to home-birth practice.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of specific requirements for midwives’ training and ongoing exposure to home births
Wider context from the report
“1. I am concerned that the two midwives who attended Emilia’s mother at home had limited experience of home births. One was a newly-qualified midwife who actually had more experience in home births than the other midwife; despite decades of midwifery experience she had never attended a home birth before. I heard evidence that there is no specific regulatory requirement regarding midwifery experience at home births and that training to become a midwife requires attendance at 40 births of unspecified type. During the inquest it was set out that home births occur relatively infrequently and that it can be difficult to ensure involvement in such births during training. I also heard that some midwives tend to focus on specific areas of practice, such as low-risk or high-risk births and that their experience in other areas can therefore be limited. This is despite the potential need for any midwife to attend low-risk births and the regulatory requirement that midwives ensure competency in all areas of practice. I asked the hospital Trust involved for information as to how they ensure that midwives have appropriate experience in home birthing. They have set out as follows: The lead midwife has previous experience (gained knowledge and skills through direct observation and participation) of attending and facilitating a home birth or birth in a low risk setting The lead midwife normally works in a low risk birth setting i.e Community midwife or Bluebell birth centre midwife The lead midwife is competent and up to date with their mandatory training within a home birth or low risk birth setting thus demonstrating the knowledge and skills required. However, the concern remains that there is seemingly no specific regulatory requirement for training or ongoing exposure to areas of practice that midwives may encounter, in particular the unique issues that can arise during home births. ”
Source location
Emilia Watson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
31 Jul2014
Manchester South
Concerns raised1
1. Unavailability of midwives for timely attendance at planned home births
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Reconnect the faulty dedicated telephone line.
  Stated by Manchester University NHS Foundation TrustStated completed
2. Action
  Provide women with two telephone numbers for planned home-birth support.
  Stated by Manchester University NHS Foundation TrustStated completed
3. Action
  Establish a standard operating procedure for checking essential telephone lines function at the start of each shift.
  Stated by Manchester University NHS Foundation TrustStated completed
AI-generated summary

Antonio Jerome Allen · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Antonio Jerome Allen was admitted to Trafford General Hospital in cardiac arrest on 26 June 2013 after being found unresponsive at home, and could not be revived. Concerns were raised that midwives could not be contacted for the planned home birth and arrived only after the delivery had occurred.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of midwives for timely attendance at planned home births
Wider context from the report
“It had been arranged that this was to be a home birth and the midwives based at Lostock Medical Centre were aware of this. His expected date of delivery was the 15th June but in fact he was born on the 17th June. The mother and grandmother of Antonio tried on four separate occasions to call out a midwife to attend the birth but in fact the delivery had to be carried out by the grandmother and a neighbour. Two midwives eventually arrived, checked the baby and said all was well although he was a bit ‘puffy’ because it was a ‘quick birth’. IF A HOME BIRTH IS BOOKED AND EXPECTED OR INDEED OVERDUE, IT SHOULD NOT BE THE CASE THAT THE MIDWIVES ARE NOT CONTACTABLE, NOR THAT THEY ARRIVE AFTER THE BIRTH HAS OCCURRED. ”
Source location
Antonio Jerome Allen · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Reconnect the faulty dedicated telephone line.

Verbatim wording from the response
“On being informed by Midwife ████████ of the unanswered phone calls the administrator notified switchboard of the fault on the line and immediate action was taken to reconnect the telephone line. To ensure that this never happens again women are now given two telephone numbers to call in case one line is busy or faulty. A standard operating procedure in place to check that the essential telephone lines are fully functioning.”

Source location
2014-0351-Response-by-Central-Manchester-University-Hospitals-NHS
Page 2 · response
Published 31 July 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide women with two telephone numbers for planned home-birth support.

Verbatim wording from the response
“On being informed by Midwife ████████ of the unanswered phone calls the administrator notified switchboard of the fault on the line and immediate action was taken to reconnect the telephone line. To ensure that this never happens again women are now given two telephone numbers to call in case one line is busy or faulty. A standard operating procedure in place to check that the essential telephone lines are fully functioning.”

Source location
2014-0351-Response-by-Central-Manchester-University-Hospitals-NHS
Page 2 · response
Published 31 July 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish a standard operating procedure for checking essential telephone lines function at the start of each shift.

Verbatim wording from the response
“Following her return to the hospital Midwife ████████ alerted the radio telephone administration staff of the difficulties experienced by the family. On investigation it was identified that there had been a known fault on the telephone line earlier in the day but this had been resolved by the engineers. There is a process in place to ensure that the essential telephone lines are checked at the beginning of each shift; it was apparent that the administrator did not follow the process for checking the phone line at commencement of their shift so was unaware that the fault had reoccurred.”

Source location
2014-0351-Response-by-Central-Manchester-University-Hospitals-NHS
Page 2 · response
Published 31 July 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to hold a multidisciplinary risk discussion for an unsafe home birth

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised6

Lack of guidance on the threshold for transfer from home birth to hospital

Lack of guidance on midwife training for competent home birth management

Lack of guidance on midwife experience requirements for home birth management

Lack of guidance on backup arrangements for electronic system failure during home births

Lack of guidance on safe home birth staffing and equipment levels

Lack of national guidance on the home birth model of care

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.9

Concerns raised6

Unavailability or significant delay of required interventions during high-risk home births

Lack of national data collection on home birth transfers, outcomes and out-of-guidance care

Inconsistent models of home birth care

Lack of a national framework for safe home birth eligibility and midwifery practice

Lack of national guidance on staffing, training and experience for home birth midwives

Lack of bespoke training needs analysis for home birth team midwives

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.16

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.17

Actions described in response 1

Respondent positions 4

Actions described in response 6

Respondent positions 9

Actions described in response 16

Respondent positions 17