PFD report

Phoenix Grace CHAPMAN · Prevention of Future Deaths report

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Issued 14 Jul 2023•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns: 2
Recipients: 1
Responses found: 2
Stated actions: 12

Recipients and published responses

Homerton Healthcare NHS Foundation TrustResponse found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 3 August 2022, I commenced an investigation into the death of Phoenix Chapman, a baby who died less than six weeks after he was born. The investigation concluded at the end of the inquest on 7 July 2023. I made a determination at inquest of death by natural causes.

I recorded the medical cause of death as:

1a) hypoxic ischaemic encephalopathy and bronchopneumonia
1b) peripartum asphyxia
1c) cord compression
2 vaginal breech delivery and unplanned home delivery

Coroner’s concerns

That Phoenix’ death was and remains utterly devastating for his parents is unsurprising. However, it was clear at inquest that it was also deeply shocking for those trying to care for him and his mum. Events were outside the experience of several of the healthcare professionals involved.

I heard at inquest that new national maternity guidance is to be published at the end of the month. This will include within it revised advice for paramedics faced with an unplanned home delivery such as this one to transport to hospital even if birth is imminent. I was assured at inquest that the advice will quickly be disseminated.

Had I not been given this information, I would have made a prevention of future deaths report to the ambulance service.

It is of course of the utmost importance that hospital clinicians and ambulance clinicians have the same understanding of how a patient in any given situation should be treated, and I have copied this report to the London Ambulance Service (LAS).

The reason I make a report to the Homerton, is because it seemed to me at inquest that there were two matters that had not yet been resolved.

i) At inquest, there was not a shared understanding among the clinicians within the trust about how such a situation should be approached.

The obstetricians were clear that, given her very high risk status, Phoenix’ mum needed to come in to hospital as soon as she showed the first signs of labour. And even if she had started to deliver, she could still only be treated effectively and Phoenix given the best chance of a good outcome in hospital.

However, some of the midwives felt strongly that, when Phoenix’ dad could see the baby’s leg emerge, they should have been allowed to go out to the home to give whatever assistance they could.

All the clinicians need have the same understanding of the correct protocol.

ii) A related point is that, before Phoenix was born, some of the midwives felt that their views of what should happen in the event of precipitous labour had not been taken seriously.

If they are to be effective in their role, and if necessary to understand why a protocol does fully reflect their feelings and views, the midwives’ ability to communicate with senior management needs to be enhanced.

If the team as a whole is to move forward in a way that provides the best possible care for women in labour and their babies, questions and differing opinions need to be in some way acknowledged and dealt with before the correct protocol can be embedded.

Concerns and recipient responses

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Concerns raised2

Lack of shared understanding among clinicians about the correct protocol
Failure to ensure that midwives’ views and differing opinions about precipitous labour are communicated and addressed
Part of recurring concern: Failure to maintain an open and accountable safety culture

Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response 7

Action
Implement the North East London pathway requiring hospital transfer for most Birth Before Arrival cases, while requesting a midwife when conveyance is declined.
Stated by London Ambulance Service NHS TrustStated completed
Action
Assign a senior consultant obstetrician to the homebirth midwifery team and its monthly meetings to support case discussion, collaboration and sharing of learning.
Stated by Homerton Healthcare NHS Foundation TrustStated completed
Action
Work with the London Ambulance Service and North East London maternity system to formulate local standard operating procedures and guidance for imminent births and hospital-transfer refusals.
Stated by Homerton Healthcare NHS Foundation TrustStated in progress

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 5

1
Share the case anonymously with ambulance maternity leads, medical directors and the JRCALC development group, and feed its learning into JRCALC.
Stated by London Ambulance Service NHS TrustStated planned
2
Publish the approved updated national breech-birth guidance in the next JRCALC guideline update.
Stated by London Ambulance Service NHS TrustStated planned
3
Update and approve national breech-birth guidance, incorporating revised timing advice and visual prompts for ambulance clinicians.
Stated by London Ambulance Service NHS TrustStated completed
4
Employ a Specialist Birth Options Midwife to coordinate plans for mothers choosing birth outside guidance and share finalized plans with relevant clinical teams.
Stated by Homerton Healthcare NHS Foundation TrustStated completed
5
Alert the London Ambulance Service to out-of-guidance birth plans so it is aware of the cases and emergency-management plans.
Stated by Homerton Healthcare NHS Foundation TrustStated completed

Recipient positions 3

1
For imminent birth, attempting delivery at the scene is considered safer than transporting the woman to hospital before delivery.
Stated by London Ambulance Service NHS TrustDisputes the concern
2
The North East London pathway applies only to births before ambulance arrival, not normal labour, obstetric emergencies or breech births.
Stated by London Ambulance Service NHS TrustDisputes the concern
3
Nationally developed, evidence-based JRCALC guidance with expert input and continuing review is considered an adequate response for ambulance clinicians.
Stated by London Ambulance Service NHS TrustExisting arrangements considered sufficient

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised2

Lack of shared understanding among clinicians about the correct protocol

Failure to ensure that midwives’ views and differing opinions about precipitous labour are communicated and addressed

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3

Actions described in response 7

Recipient-stated actions 5

Recipient positions 3