NHS criticised after avoidable home birth death

A coroner found a newborn's death after a home birth was avoidable, citing staffing and monitoring failures; the senior coroner said she will write to the Health Secretary and national bodies about the lack of home-birth guidance.

A coroner in Cheshire recorded that the death of a newborn following a planned home birth was avoidable. The inquest heard the home birth team was already attending another delivery over a Bank Holiday and that staffing pressures reduced available, experienced midwifery support. Those who attended were reported to carry out few home births each year and monitoring of the baby was disrupted, which delayed transfer to hospital. The senior coroner said she will write to national health bodies about the absence of formal guidance on home births. What the inquest found: - The coroner concluded the baby's death was avoidable and linked it to delays in transfer and delivery. - The home birth team was already engaged elsewhere and the Trust could not support two home births at the same time. - Two of the three attending midwives were community midwives who, on average, assisted with only a small number of home births annually, and monitoring was affected by staffing and IT problems. - The senior coroner will write to the Health Secretary, Department of Health and Social Care, NHS England and NICE about national guidance; the local Trust has since changed its home-birth arrangements. Summary: The coroner's findings identify staffing and monitoring shortfalls in community midwifery care and signal a concern about the absence of national home-birth guidance. The senior coroner will notify national health bodies and the Trust has altered its local home-birth policy; further national action is undetermined at this time.