Coroner calls for review after Hampshire baby dies, with doula "negatively" impacting role of midwives
A coroner has warned that without proper guidance over the use of doulas, more babies could be at risk following the tragic death of Matilda Pomfret-Thomas in 2023.
A prevention of future deaths report has been issued by assistant coroner for Hampshire, Portsmouth and Southampton, Henry Charles, to review “issues” surrounding the role of doulas during childbirth.
This comes after Matilda Pomfret-Thomas’s parents hired a doula as part of a plan to give birth at home following a traumatic hospital birth with their first child.
A doula is an unregulated, non-medical professional that some parents employ to provide emotional and practical support during pregnancy and birth.
But the role of doulas has proved controversial, with some arguing they play a key role in supporting women – while others, including some doctors, say they put women and babies at risk.
Baby Matilda died aged 15 days on November 13, 2023, from neonatal hypoxic-ischemic encephalopathy (HIE) which is a type of brain damage caused by a lack of oxygen to the brain before or during birth.
Mr Charles recorded a narrative conclusion that Matilda developed HIE while at home and the presence of a doula “negatively impacted” midwives being able to provide advice to the mother and usual care.
He said meconium, which is the baby’s first stool, and decreases in foetal heart rate were observed by midwives attending the home birth.
However the mother was not taken to hospital following those complications becoming apparent until 12.13pm, and Matilda was eventually delivered at Queen Alexandra Hospital.
In his latest report, Mr Charles wrote: “The background is of a traumatic first birth that impacted upon decision making for this second pregnancy and birth.
“Matilda’s parents had seen a home birth as the best way forward.
“Labour started in the early hours of October 29, 2023 and there was prompt midwife attendance.
“An initial and appropriate offer at 7.19am of transfer to hospital upon meconium being found was not accepted, thereafter the implications of a deteriorating situation involving decelerations against a background of the presence of meconium – including further clear signs of it at 10am, requiring hospital transfer, was not communicated in such a way as to lead to a transfer to hospital.
“An element of what occurred is that the presence and work of a doula did on this occasion negatively impact upon the effective provision of midwifery services in terms of building a rapport conducive to effective advice and care being given.”
“The hospital’s preference was for a hospital delivery, there was discussion as to what circumstances would result in the mother being blue lighted to hospital,” he said in the report.
The report also explained: “A difficult atmosphere had developed, the midwives felt access was being restricted by the doula.
“I found that she did not actively discourage midwife access but that she was seen as, in effect, a buffer by members of the midwifery team.”
The coroner noted that the organisation Doula UK “is the largest representative body for doulas, but it is not a regulatory body, it does not represent all doulas, indeed many doulas are not members of Doula UK.”
The Maternity and Newborn Safety Investigations (MSNI), which investigates patient safety incidents in NHS maternity care, said in its report into the birth, cited by the coroner, that there were issues with how doulas and midwives work together.
“MNSI acknowledges that there is no regulation of doula care or any guidance on how the two services interact with each other,” Mr Charles said.
“MNSI considers the dynamics of a situation, where a third party are involved can provide additional challenges for staff, such as making clinical recommendations against personal recommendations or views and providing usual care that could be viewed as interference rather than surveillance.”
The coroner said MNSI has identified 12 cases where “doulas worked outside of the defined boundaries of their role and in which the care or advice provided by the doula was considered to have potentially had an influence on the poor outcome for the family.”
His report, which is being sent to the Department of Health, the Nursing and Midwifery Council, Doula UK and others, said: “The issues of doula registration, regulation and training are therefore points of concern I would commend for review.”
A spokesperson for Doula UK told the Guardian: “We take the implications of the coroner’s report extremely seriously.
“We have policies and practices in place to protect members and the families they support to ensure doulas remain within the scope of their practice and, in light of the report, we will be taking steps to review and strengthen our policies, guidance and ongoing CPD provision in consultation with our members and approved course providers.
“In September 2025, Doula UK and the Nursing and Midwifery Council also collaborated on a video series clarifying the distinct roles of midwives and doulas.”