Jennifer Cahill and Agnes Cahill

Association of Ambulance Chief Executives 
25 Farringdon Street 
London 
EC4A 4AB 

17/12/2026 

BY EMAIL 

Dear Stephanie, 

Subject: Request for Review and Update to JRCALC Postpartum Haemorrhage (PPH) 
Guidance Following a Maternal Death. 

I am writing in response to your letter dated 23 October 2025, in which you raised clinical 
concerns regarding the JRCALC Post-partum Haemorrhage guideline. I am replying on behalf of 
AACE and in my capacity as Chair of the JRCALC Guidelines Committee. Please be assured that 
we take all concerns raised with us very seriously and remain committed to ensuring our guidance 
is both safe and evidence-based. 

As you are aware, we have liaised with you and our JRCALC RCOG members to address the 
issues you highlighted. I would like to outline the actions taken in response: 

•  Application of direct pressure in suspected trauma: We have amended the main body 
of the guideline and the “Key Points” section to clarify that if bleeding persists despite a 
firm uterus, other causes should be reconsidered (trauma, tissue, thrombin). 

•  Frequency of observations: The guidance specifies that continuous observations form 
part of ongoing management, particularly in the presence of major bleeding. This aligns 
with your recommendation for close monitoring in women at risk of PPH. 

•  Availability of first-line uterotonics: The issue of national standardisation has been 

debated extensively within JRCALC and beyond. It remains the responsibility of individual 
ambulance services to determine which drugs they carry, as there is no single uterotonic 
agent clearly recommended for use in the pre-hospital setting. 

We trust these clarifications address the concerns you raised. Thank you for engaging with us to 
ensure our guidance continues to reflect best practice and patient safety. 
Yours sincerely, 

Chair, JRCALC Guidelines Committee  
On behalf of AACE 

A20

Parliamentary Under-Secretary of State for 
Women’s Health and Mental Health 

39 Victoria Street 
London 
SW1H 0EU 

HM Coroner Joanne Kearsley 
The Coroner’s Office, 2nd and 3rd Floor, Newgate House, Newgate, Rochdale OL16 1AT 
01706 924815 

5 March 2026 

Dear Ms Kearsley, 

Thank you for the Regulation 28 report of 5 November 2025 sent to the Secretary of State / 
the Department of Health and Social Care about the death of Jennifer and Agnes Cahill. I 
am replying as the Minister with responsibility for Maternity, Women’s Health and Mental 
Health.   

Firstly, I would like to say how saddened I was to read of the circumstances of Jennifer and 
Agnes death. I offer my sincere condolences to their family and loved ones. The 
circumstances your report describes are very concerning and I am grateful to you for 
bringing these matters to my attention. Thank you for the additional time provided to the 
department to provide a response to the concerns raised in the report. I recognise the 
seriousness of the matters raised in your report and the need for urgent action to improve 
the safety and quality of homebirth services.   

The report raises concerns over: 

1.  There is no national guidance in respect of home births. Specifically, robust 

evidenced based guidance on home birth care, similar to that which is in place for 
intrapartum care in a hospital setting. 

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. 

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 

A36 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 national guidance considering the ethical responsibility and proportionality of offering 
a home birth model under the NHS framework. 

4.  Even though there is a very small risk of death, this is not something which is 

discussed with women particularly in relation to maternal death, even if the woman 
has a recognised risk such as a post-partum haemorrhage. There is no guidance to 
ensure the risk of death to both mother and baby is discussed with any woman 
considering a home birth irrespective of being considered high or low risk. 

5.  NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 only 

refers to the potential risk of death to a baby. There is no mention in the guidance of 
risk to the mother. 

6.  Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ 
and leads women to consider that pregnancy encompasses all stages through to 
delivery of a child. Practice does not personalise or individualise risk so women can 
fully understand what the level of risk is for them in actually being pregnant, or what 
the level of risk is for them in giving birth. 

7.  In order to maintain their skills, there is no set number of deliveries a community 
midwife must conduct following qualification. There is no mandated number of 
deliveries that any midwife (irrespective of the settings in which they are working) 
must complete once they have qualified as a midwife in order to maintain their 
registration. The level of experience of community midwives in conducting deliveries 
is not information routinely provided to women to inform their decision whether to 
have a homebirth. 

8.  No bespoke training needs analysis has been conducted focusing on midwives 

practicing in home birth teams. 

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. 

10. The no national guidance on the model of staffing, training and experience for 

midwives providing home birth care. 

In preparing this response, my officials have made enquiries with NHS England to ensure 
we adequately address your concerns. 

NHS England’s letter to Trusts sent on 25 November directed all Trusts to urgently review 
their homebirth services. This letter directly highlights three matters raised in your report: 
operational running of services, care planning and risk assessment, governance and 
oversight. NHS England set a clear expectation for Trusts to report the findings of their 
review to their local board and to escalate any issues identified for further action to the 
Regional NHS Team.  

I recognise and agree that the guidance relating to intrapartum care does not provide the 
clarity necessary to support women, staff and services to support home birth requests 
safely.  NHS England have started to develop further resources, and I welcome the 

A37 
 
 
 
 
 
 
 
 
  
  
 
 collaboration of the NICE, Royal College of Midwives, Royal College of Obstetrics and 
Gynaecology, Nursing and Midwifery Council, Maternity and Newborn Safety Investigations, 
Care Quality Commission and the General Medical Council in this work. These resources 
will take account of the matters raised in your report and will specifically address the 
increase in the number of women with “high risk pregnancies” requesting home births and 
variation in service models. 

You have raised an important issue relating to the ethical responsibility and proportionality 
of offering, and women choosing, a homebirth. It is an incredibly personal choice for women 
about how they wish to give birth and they have a legal right to choose what healthcare 
they need. I want to acknowledge that women can choose an unsupported homebirth if they 
wish which carries a greater risk to the women and the baby. I agree that we need to 
consider this matter closely and will discuss with NHS England what further guidance is 
needed to better support Trusts manage these finely balanced situations. My officials will 
also engage with NICE to amend their intrapartum guidance to reflect the risk of maternal 
death.  

I wholeheartedly agree that all risks throughout pregnancy, particularly the risk of death to 
both the mother and baby, must be discussed sensitively and fully with women. Whilst this 
is important for every woman regardless of the level of risk associated with the pregnancy, it 
is even more critical for women who identified as high risk. I am deeply sorry that for 
Jennifer, this did not happen, and we must ensure this does not happen again. The Nursing 
and Midwifery Council has guidance for midwives to support informed decision making, 
principles for supporting women’s choices throughout their maternity care and for outside of 
hours care. It is the responsibility of Trusts to ensure care is delivered in line with these 
standards.  

It is critical to the safety of women that they receive a risk assessment at each point of 
contact throughout their pregnancy. This was a recommendation made by Donna 
Ockenden, in her independent review of maternity services at Shrewsbury and Telford in 
2022. The previous Government accepted all the recommendations in this report and in 
November 2025 all Trusts were directed to implement this as part of its response. Following 
Donna’s recommendations in 2022, NHS England carried out regional assurance site visits 
at Trusts, and all Trusts reported compliance with implementation to their regional teams.  

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. 

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.  

A38 
 
 
 
 
 
 
 I recognise the need to improve the data collection in relation to number of women who 
transferred during labour and after birth as well as maternal and neonatal outcomes. I 
support NHS England’s proposal to work with the Midwifery Study System to develop a 
solution to this. 

It is vital that lessons are learnt collectively, and changes are made to reflect where things 
have gone wrong, which is essential to ensure the NHS provides safe, high-quality care. 

I hope this response is helpful and we will continue to work closely with NHS England and 
other partners to bring forward quick action to address your concerns.  

All good wishes, 

A39

Ms Joanne Kearsley 
HM Senior Coroner  
Manchester North  
The Coroner’s Office 
2nd and 3rd Floor 
Newgate House  
Newgate 
Rochdale  
OL16 1AT 

Dear Coroner, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

24 December 2025  

Re: Regulation 28 Report to Prevent Future Deaths – Jennifer Rose Cahill who 
died on 4 June 2024 and Agnes Lily Wren Cahill who died on 7 June 2024.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  5 
November 2025 concerning the sad deaths of Jennifer Rose Cahill on 4 June 2024 
and her daughter, Agnes Lily Wren Cahill, on 7 June 2024. In advance of responding 
to  the  specific  concerns  raised  in  your  Report,  I  would  like  to  express  my  deep 
condolences to Jennifer’s and Agnes’ family and loved ones. NHS England is keen to 
assure the family and yourself that the concerns raised about Jennifer’s and Agnes’ 
care have been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any  anguish  this  delay  may  have  caused  Jennifer's  and  Agnes’  family  or  friends.  I 
realise that responses to Coroners’ Reports can form part of the important process of 
family and friends coming to terms with what has happened to their loved ones, and I 
appreciate this will have been an incredibly difficult time for them. 

Your  Report  raised  a  number  of  concerns,  which  we  have  considered  in  full.  The 
concerns that fall within NHS England’s role and remit relate to the lack of national 
guidance  in  relation  to  homebirths  and  associated  maternity  care,  and  the  current 
differing models of care and practice across the country. You also raised that there is 
a lack of national data collection, meaning there is no data to evidence the number of 
women who are transferred from home to hospital during labour or after birth, maternal 
or neonatal outcomes, and the number of women considered out of guidance. 

We have engaged with colleagues from NHS England’s national maternity team as 
well as our North West regional team in preparing the response to your Report.  

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: 

A15                                                                                                                       
 
 
 
 
 
  
 
  
 
 
 
 
 
 
 
 •  The operational running of their service: including how it ensures that prompt 
midwifery care is available 24 hours a day; that staff are properly equipped, trained, 
prepared and skilled for providing birth and neonatal care in a home setting; that 
staff have senior multi-disciplinary support available to them at all times and have 
sufficient  rest  periods;  and  that  potential  transfer  and  extraction  processes  are 
clear and planned for each birth. 

•  Care  planning  and  risk  assessment:  including  systematic  assessment  of 
complexity and risk; how the multidisciplinary team (MDT) ensures a personalised 
approach to women in planning care in light of any identified issues (particularly 
when a homebirth is not recommended); how the MDT continues to maintain good 
communication at all stages of care with women and between all teams including 
ambulance  services;  and  how  dynamic  risk  assessment  is  managed  and 
responded to throughout pregnancy, birth and the postnatal period.   

•  Governance  and  oversight:  including  how  governance  is  structured  to  ensure 
robust oversight of homebirth services by the whole organisation, so the trust board 
has appropriate oversight; that there is an audit programme that covers outcomes 
and clinical and operational guidance and leads to continuous improvement; and 
that  there  is  comprehensive  homebirth  guidance  including  standard  operating 
procedures for all stages and aspects of care.  

The National Institute for Heath and Care Excellence (NICE) uses available evidence 
to  develop  guidance  to  improve  health  and  social  care,  including  the  Guideline  on 
Intrapartum care (published 29 September 2023 and updated on 14 November 2025). 
While not dedicated to homebirths, the guidance does cover the care of women and 
their  babies  during  labour  and  immediately  after  birth  in  all  settings  and  addresses 
issues around planning the place of birth. 

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.  

In  December  2025,  NHS  England  convened  partners  and  initiated  work  to  develop 
resources that rapidly close this gap. This will include how to respond to the increase 
in  the  number  of  women  with  “high  risk  pregnancies”  requesting  homebirths  and 
variation in service models.  

In developing these resources, NHS England and its partners will consider the ethical 
responsibility and proportionality of offering women an NHS homebirth, while taking 
into account that women have a legal right to choose what healthcare they receive. In 

A16  
  
  
  
  
  
 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.  

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.  

We agree that patients should be informed about all material risks, and this has been 
established by case law relating to informed consent. Health professionals must take 
“reasonable care to ensure that the patient is aware of any material risks involved in 
any recommended treatment and of any reasonable alternative or variant treatments”. 
With regard to the risk of death, this is better framed in terms of the risk of potential 
adverse outcomes, such as post-partum haemorrhage, and how mitigations might vary 
in different settings.  

For all women, communication around risk should be personalised. Donna Ockenden, 
in her review of the maternity services at Shrewsbury and Telford Hospital NHS Trust, 
made it clear that staff must ensure that women undergo a risk assessment at each 
contact  throughout  the  pregnancy  pathway  and  that  “risk  assessment  must  include 
ongoing  review  of  the  intended  place  of  birth.”  NHS  England  asked  Trusts  to 
implement this at the time. All pregnant women should also be offered a personalised 
care  and  support  plan  where  such  information  is  recorded,  alongside  the decisions 
they make about their care. 

The  Royal  College  of  Midwives  (RCM)  has  separately  issued  guidance  around 
Informed decision making and Care outside of guidance, and the Nursing & Midwifery 
Council  (NMC)  has  issued  Principles  for  supporting  women's  choices  in  maternity 
care. Employing Trusts are responsible for ensuring that their midwives practice in line 
with these principles. 

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. 

A17  
  
  
 
  
  
 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. 

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. 

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. 

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports  received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  deaths  of 
Jennifer and Agnes, are shared across the NHS at both a national and regional level 
and helps us to pay close attention to any emerging trends that may require further 
review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

A18  
  
  
 
  
 
 
  National Medical Director 
 NHS England 

A19

3rd floor 
3 Piccadilly Place 
Manchester 
M1 3BN 
United Kingdom 

22 December 2025  

Ms Joanne Kearsley  
HM Coroner's Officer 
HM Coroner’s Court 
Floors 2 & 3, Newgate House, Newgate,  
Rochdale,  
OL16 1AT  

Dear Ms Kearsley 

Re: Regulation 28 Prevention of Future Deaths Report (Jennifer and Agnes Cahill)  

I write in response to your regulation 28 report dated 5 November 2025 regarding the very sad death of 
Jennifer and Agnes Cahill. I would like to express my sincere condolences to Jennifer’s and Agnes’s 
family.   

I asked the patient safety leads at NICE to carefully consider your report with respect to the areas for 
which NICE is responsible, and I address each point in turn. 

1.There is no national guidance in respect of home births 

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 6-9. The guideline provides comprehensive 
guidance on intrapartum care, including (but not limited to) home births. The guideline covers: 

•  Eligibility - home birth might be considered for women with low-risk, uncomplicated pregnancies. 
This includes those without medical or obstetric complications and differentiates in terms of risk 
factors between nulliparous and multiparous women (recommendation 1.3.1). 

• 

Informed Choice: Women should be supported to make informed decisions about their place of 
birth. This includes discussing risks, benefits, and available support (recommendation1.3.3-5). 

•  Midwife Support: Care during home birth should be provided by trained midwives, with access to 

emergency transfer protocols if complications arise. 

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 6-9. 

nice.org.uk | nice@nice.org.uk 

A21 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 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 led 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. 

We therefore conclude that the subject of home births is appropriately covered in the current guidelines. 
The recommendations guide clinical practice and support women to make an information choice about 
their care based on discussions with trained staff about the risks and benefits. There is insufficient 
evidence to suggest that a change to the current recommendations is justified.  

2. 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. 

As noted above, our guidance on intrapartum care (NG235) lists medical conditions and other factors 
that may influence the choice of planned place of birth (tables 6-9). These 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 her baby.  

Further discussion with an appropriately trained senior or consultant midwife and/or a senior or 
consultant obstetrician (if there are obstetric issues) is recommended (recommendation 1.3.10).  

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. 

We note that the coroner dislikes the term 'birth outside of guidance' but the language associated with 
this term has been carefully chosen to reflect the sensitivities around discussions where women have felt 
in the past that their care has been paternalistic and choice has been removed from their care.  

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. 

3.There is no national guidance considering the ethical responsibility and proportionality of 
offering a home birth model under the NHS framework. 

The ethics of service delivery for an individual health care worker are covered by the relevant regulator. 
For example, the Nursing and Midwifery Council (NMC) and the General Medical Council (GMC) along 
with the Department of Health and Social Care (DHSC) and NHS England (NHSE).  

4.There is no guidance to ensure the risk of death to both mother and baby is discussed with any 
woman considering a home birth irrespective of being considered high or low risk. 

NICE provides a number of tools and resources to support our guidelines. For intrapartum care (NG235), 
these include a tabulated comparison of the different places of birth containing an estimate of the risks to 
the mother and the baby. There is also a link to endorsed resources produced by NHS England that 
support the implementation of the recommendations in this guideline.  

Our patient safety leads note that maternal death is a rare event in modern UK maternity care; 
population surveillance (MBRRACE-UK) reports maternal mortality at the level of ~9–13 deaths per 
100,000 maternities in recent periods, which reflects deaths across all settings and risk groups and 

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A22 
 
 
  
  
 
 
 
 
 
 
  
 
  
 
 
 cannot be disaggregated reliably by planned place of birth in most studies. The absolute number of 
maternal deaths is extremely small, so studies are not able to compare maternal death rates specifically 
by planned place of birth. 

We are aware that The Birthplace Study found that for multiparous women home births are as safe as 
hospital births. For first-time mothers, there is a slightly increased risk of adverse outcomes for the baby. 
Our patient safety leads are not aware if home births, as currently practised in the UK, are any more or 
less safe for women. This is supported by a meta-analysis published in 2019 Perinatal or neonatal 
mortality among women who intend at the onset of labour to give birth at home compared to women of 
low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses - 
ScienceDirect. 

Furthermore, as most home births are in low-risk pregnancies (as per the guidance) determining a risk of 
mortality for those at greater risk is not possible from observational studies. Our view is that further 
research is needed by the appropriate bodies to quantify the risk in an individual.  

5. NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 only refers to the 
potential risk of death to a baby.  There is no mention in the guidance of risk to the mother. 

For healthy, low risk women the absolute risk of maternal death during or soon after labour is extremely 
low and too small for robust direct comparison between planned home birth, midwifery unit birth, and 
obstetric unit birth in the UK. High quality population evidence (the Birthplace programme and related 
evidence reviews) finds no clear increase in serious maternal outcomes for low risk women planning 
birth in midwifery units or at home, but maternal death is so rare that studies are underpowered to detect 
small differences in that specific outcome.  

For clinically low risk women, national evidence supports offering a choice of home birth or midwifery unit 
birth with careful antenatal assessment and tested transfer arrangements; obstetric units remain the 
recommended setting for women with identified clinical risk factors because they provide immediate 
access to higher level interventions should rare but serious complications (including those that might 
lead to maternal death) occur.  

NICE guidance on intrapartum care (NG235) includes a recommendation for research into the effect of 
information-giving on place of birth. Such research may be used to restructure the way in which 
information is provided, so that it is presented in a more accurate, less risk-based way in order to support 
women's choices. 

The NICE guideline, as detailed earlier in this response, does include recommendations on medical 
conditions and other factors that may affect planned place of birth. Those recommendations include 
consideration of risk to the mother.  

6.Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’. 

We note your suggestion that as terminology around pregnancies describes them as ‘high’ or ‘low risk 
pregnancy’, this leads women to consider that pregnancy encompasses all stages through to delivery of 
a child, and that this does not allow people to differentiate between the level of risk for them in being 
pregnant and the risk of labour and birth itself.   

We do not define the use of the term ‘low-risk pregnancy’, that is ‘one where both mother and baby are 
expected to remain healthy throughout pregnancy and birth. The term explicitly covers risks to both the 
mother and the child, but it signals that the likelihood of complications is low, not non-existent’.  

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3 of 4 

A23 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 There is a discussion about this in the final scope (the final scope defines what the guideline will and will 
not cover and to whom it will apply) for intrapartum care for women with existing medical conditions or 
obstetric complications and their babies (NG121). It defines a high risk pregnancy: 
“A pregnancy is 'high risk' when the likelihood of an adverse outcome for the woman or the baby is 
greater than that of the 'normal population'. A labour is 'high risk' when adverse outcomes arise in 
association with labour.” 

We will review our guidance to consider the feasibility of defining what is meant by high and low risk 
pregnancy and making the differentiation clear between the risks of pregnancy and the risks of labour.  

Points 7-9 do not relate to the role of NICE. 

10.The no [sic] national guidance on the model of staffing, training and experience for midwives 
providing home birth care. 

Our guideline on safe midwifery staffing for maternity settings (NG4) covers midwifery staffing in all 
maternity settings, including at home and in the community. It aims to improve maternity care by giving 
advice on monitoring staffing levels and actions to take if necessary. It provides recommendations on 
organisational requirements; setting the midwifery establishment; assessing differences in the number 
and skill mix of midwives needed and the number of midwives available; and monitoring and evaluating 
midwifery staffing requirements.  

The guideline also provides recommendations on assessing the skill mix of available maternity staff 
against care requirements.  

Additionally, there are the tools referred to under point 4 above.  

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. 

I hope that the information above is helpful in clarifying the guidance that we have published that is of 
relevance to the circumstances of these very sad events and would like to reiterate my sincere 
condolences to the family of Jennifer and Agnes.  

Yours sincerely, 

Chief Executive 

, CBE MD FRCS FRCEM 

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4 of 4 

A24

Senior Coroner Joanne Kearsley 
HM Coroner’s Court 
Floors 2 and 3 
Newgate House 
Newgate 
Rochdale 
OL16 1AT 

12 January 2026 

Dear Coroner 

Regulation 28 Prevention of Future Deaths report dated 5 November 2025 in 
relation to Jennifer and Agnes Cahill 

I would like to begin by offering my heartfelt condolences to the family of Jennifer 
and Agnes for their tragic loss.  

As Chief Executive and Registrar of the Nursing and Midwifery Council (NMC), I take 
the matters of concern set out in your report very seriously. Our vision is to provide 
safe and effective midwifery education and practice across the four countries of the 
UK. In line with this, I set out below the steps we will be taking to the address the 
issues in relation to home births identified as part of your investigations. 

First, and by way of background, I thought it would be helpful to set out the NMC’s 
role and to detail some of the work already underway to ensure safe, equitable and 
person-centred maternity care in the UK. 

NMC’s regulatory role  

The NMC is the independent regulator for nurses and midwives in the UK, and 
nursing associates in England. Our role is to protect the public and maintain 
confidence in the nursing and midwifery professions.   

We support more than 47,400 midwives to deliver safe and effective midwifery care 
through our regulatory processes. We do this by setting the standards of conduct 
and performance through the Code and competencies through the standards of 
proficiencies, which specify the knowledge, understanding and skills that midwives 
must demonstrate at the point of qualification, when caring for women across the 
maternity journey, newborn infants, partners and families across all care settings.  

A25 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The standards of proficiency are in alignment with the International Confederation of 
Midwives’ (ICM) definition of the midwife and the ICM essential competencies for 
midwives and are based on the Lancet framework for quality maternal and newborn 
health: 

The above explains how the proficiency standards are developed and must be read. 
The different domains are all inter-connected and together demonstrate the 
expectations from all midwives. Domains 1, 2 and 3 are about universal care for all 
women and newborn infants whereas domain 4 focuses on additional care for 
women and newborn infants with complications.  

In practice, midwives work across the continuum from pre-pregnancy, pregnancy, 
labour and birth, postpartum, and the early weeks of newborn infants’ life. Midwives 
are required under our standards to respect and enable the human rights of women 
and children, and their priority is to ensure that care always focuses on the needs, 
views, preferences, and decisions of the woman and the needs of the newborn 
infant.  

Our standards also require midwives to provide and evaluate care in partnership with 
women, and their partners and families if appropriate, referring to and collaborating 
with other health and social care professionals as needed. Midwives are ideally 
placed to anticipate and to recognise any changes that may lead to complications 
and additional care needs. These may be physical, psychological, social, cultural, or 
spiritual, and include perinatal loss and end of life care. When such situations arise, 
the midwife is responsible for recognising these and for immediate response, 
management, and escalation, involving, collaborating with and referring to 
interdisciplinary and multiagency colleagues. In such circumstances, the midwife has 
specific responsibility for continuity and coordination of care, providing ongoing 

2 

A26 
 
 
 
 
 midwifery care as part of the multidisciplinary team, and acting as an advocate to 
ensure that care always focuses on the needs, views, preferences and decisions of 
the woman and the needs of the newborn infant.  

Our standards recognise that midwives work in a range of roles and settings from 
women’s homes, hospitals, the community, midwifery led units and all other 
environments where women require care by midwives. As the professional regulator 
our remit is midwives as professionals. Systems regulators, such as the Care Quality 
Commission (CQC), have a role in ensuring the safety of maternity and midwifery 
services settings.   

Work underway to ensure safe, equitable and person-centred maternity care in 
the UK 

Failings by certain maternity services across the UK have come under increasing 
scrutiny over recent months and have been the subject of a number of reviews.  Too 
many women and babies have lost their lives during, or shortly after, childbirth.   

While maternity services are delivered by both doctors and midwives, as the 
regulator of midwives, we have a clear role to play in supporting the improvement of 
midwifery services. 

On 6 November, we published our Midwifery Action Plan, which outlines the work 
we are doing to ensure safe, equitable and person-centred midwifery care. This 
includes publishing the Principles for supporting women's choices in maternity 
care in August 2025 following extensive coproduction with key UK-wide lay and 
registrant stakeholders. This document outlines the support women should expect, 
the care midwives can provide and how employers can support women and 
midwives to provide safe and effective care. 

Alongside this, we are running a joint campaign with the General Medical Council 
(GMC) around the importance of high-quality multidisciplinary teamwork in maternity 
care. Good teamwork means better maternity care - The Nursing and Midwifery 
Council and Maternity care - GMC  

Actions we are taking in response to the Prevention of Future Deaths Report  

Your report highlights further issues in respect of maternity services, particularly in 
relation to home births, which we must take action to address.  

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 Resolutions (NHSR), the National Institute for Health and Care Excellence 
(NICE), the General Medical Council, Maternity and Neonatal Safety Investigations 

3 

A27 
 
 
 
 
 
 
 
 
 
 
 (MNSI), British Association of Perinatal Medicine (BAPM), the Care Quality 
Commission (CQC) and Maternity and Neonatal Voices Partnership (MNVP), and 
involved collaborative working across all key stakeholders whilst maintaining our 
independent functions. An outcome of the meeting was the development of a task 
and finish group, led by NHS England, to develop national pathways for homebirth 
services which will aim to address the matters of concern identified within the report. 
NHS England have told us that they will contact us to share proposed next steps in 
the early new year.  

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: 

1.  There is no national guidance in respect of home births. Specifically, robust 
evidenced based guidance on home birth care, similar to that which is in 
place for intrapartum care in a hospital setting 

We propose to feed into the task and finish group to address the concerns about the 
lack of national guidance in respect of home births.  

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. 

We propose to feed into the task and finish group to address the concerns about the 
lack of a robust framework for midwives supporting home birth care.  Our principles 
for supporting women’s choices in maternity care will be used to outline our 
regulatory function during these discussions. 

We will also be strengthening the NMC’s midwifery standards to acknowledge 
homebirth and the differences entailed by adding a definition to the glossary in 
explanation of all care settings by March 2026.  

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. 

We propose to feed into the task and finish group to address concerns about the 
differing models of care and lack of national guidance considering ethical 

4 

A28 
 
 
 
 
 
 
  
 
 
 responsibility and proportionality of offering a home birth model under the NMC 
framework.  

4.  Even though there is a very small risk of death, this is not something which 
is discussed with women particularly in relation to maternal death, even if 
the woman has a recognised risk such as a post-partum haemorrhage. 
There is no guidance to ensure the risk of death to both mother and baby is 
discussed with any woman considering a home birth irrespective of being 
considered high or low risk. 

We propose to feed into the task and finish group to address concerns around the 
inconsistency in evidenced based discussions with women to allow them to make 
informed choices about their birth options. 

5.  NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 
only refers to the potential risk of death to a baby. There is no mention in 
the guidance of risk to the mother. 

We propose to feed into the task and finish group to address concerns around NICE 
guidance on intrapartum care and the lack of guidance about the risks to the mother.  

6.  Terminology around pregnancies describes them as ‘high’ or ‘low risk 

pregnancy’ and leads women to consider that pregnancy encompasses all 
stages through to delivery of a child. Practice does not personalise or 
individualise risk so women can fully understand what the level of risk is 
for them in actually being pregnant, or what the level of risk is for them in 
giving birth. 

We propose to feed into the task and finish group to address concerns around the 
terminology used to describe pregnancies as “high” or “low risk”.  

7.  In order to maintain their skills, there is no set number of deliveries a 
community midwife must conduct following qualification. There is no 
mandated number of deliveries that any midwife (irrespective of the 
settings in which they are working) must complete once they have qualified 
as a midwife in order to maintain their registration. The level of experience 
of community midwives in conducting deliveries is not information 
routinely provided to women to inform their decision whether to have a 
homebirth. 

Our standards of proficiency for midwives provide that midwives should be equipped 
to care for women in all settings. Through mandatory training midwives are required 
to update their skills and competence annually ensuring they are updated within their 
current scope of practice. This is then reported to the NMC via the Continuing 

5 

A29 
 
 
 
 
 
 
 
 
 
 Professional Development (CPD) section of the revalidation process that all 
midwives must go through every 3 years to renew their registration with the NMC. 

We are not proposing to take action to introduce a mandated number of deliveries 
post-registration. There is currently no requirement for post registration confirmation 
of competence in any area of midwifery because midwives work in various areas and 
can transfer across roles regularly if they choose to do so.  

8.  No bespoke training needs analysis has been conducted focusing on 

midwives practising in home birth teams. 

We propose to feed into the task and finish group to address concerns about 
bespoke training needs analysis for midwives practising in home birth teams. 

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. 

The NMC does not hold or mandate the collection of national clinical data and so we 
are unable to take any action in response to this concern.  

10. There is no national guidance on the model of staffing, training and 

experience for midwives providing home birth care. 

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. 

Conclusion 

Thank you for sharing the areas of concern that you have identified, during your 
investigations, with us.  

I hope my setting out of our responses with respect of each concern has been 
helpful. 

6 

A30 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Once again, I would like to offer my condolences to the family of Jennifer and Agnes 
Cahill for their tragic loss.  

Yours sincerely 

Chief Executive and Registrar 

7 

A31

Private & Confidential 

Ms Joanne Kearsley, Senior Coroner 
Coroner Area of Manchester North 

7 January 2026 

Dear Ms Kearsley,  

Subject:  Royal  College  of  Midwives  (RCM)  response  to  Regulation  28:  Report  to 
Prevent Future Deaths 

Thank  you  for  your  Regulation  28  Report  to  Prevent  Future  deaths  following  the 
inquest into the death of Jennifer Cahill and Baby Agnes Cahill. 

The Royal College of Midwives (RCM) would like to begin by expressing our sincere 
condolences to the family and all those affected by the death of Jennifer and Agnes. 

The RCM is a professional association and trade union and does not hold statutory or 
operational  responsibility  for the delivery  of maternity  services.  However,  we play a 
key  role  in  representing  the  professional  voice  of  midwives,  influencing  policy, 
representing midwives and maternity support workers both individually and collectively 
in  the  workplace  and  working  collaboratively  with  practice  partners  to  advocate  for 
safe,  effective and  high-quality  maternity  care. The  response  to  this report  is  in  the 
context of our responsibilities as a stakeholder within maternity services. 

We have carefully considered the matters of concern in your report. While the RCM 
does  not  have  authority  to  implement  changes  at  service-level,  we  have  identified 
actions under each point that are within our remit and/or sphere of influence: 

A6 
 
 
 
 
 
 1. There is no national guidance in respect of home births. Specifically, robust 
evidenced based guidance on home birth care, similar to that which is in place 
for intrapartum care in a hospital setting.  

•  The  national  NICE  guideline 

‘Intrapartum  Care’ 

(2025)  makes 
recommendations on place of birth and advocates support for women in their 
choice  of  setting,  whether  that  be  at  home,  freestanding  or  alongside  a 
midwifery  unit  or  obstetric  unit.  It  states  that  those  with  previous  postpartum 
haemorrhage (PPH) should be recommended to  birth in an obstetric led unit 
and  provides  management  of  perineal  trauma,  active  management  of  third 
stage  and  initial  management  of  PPH.  Furthermore,  the  guidance  includes 
resuscitation  of  the  newborn  and  recommendations  for  emergency  referral 
pathways and transfers to an obstetric unit (if this is not the woman’s chosen 
place of birth). 

•  While the NICE ‘Intrapartum Care’ guideline (2025) provides recommendations 
on  place  of  birth,  including  supporting  women’s  choices  across  home, 
freestanding,  alongside  midwifery,  or  obstetric  units,  it  is  primarily  hospital-
focused  and  does  not  provide  a  comprehensive,  standalone  framework  for 
home birth care, staffing, skill maintenance, or emergency preparedness. 
•  NICE guidance on ‘Fetal Monitoring in labour’ (2025)  makes recommendations 
for  assessing  fetal  wellbeing  that  is  relevant  to  all  birth  settings  including  at 
home. 

•  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. 
•  The  RCM  has  ‘Care  outside  guidance’  (2022)  for midwives  to  highlight  good 
practice  when  supporting  women  who  are  considering  choices  not  within 
evidence-based guidance and aligns with the Nursing and Midwifery Council 
Principles for supporting women’s choices in maternity care (2025). A review of 
the  ‘Care  outside  guidance’  publication  is  planned  early  2026  which  will 
consider the outcomes of the  Jennifer Cahill and Agnes Cahill: Prevention of 
Future Deaths report. 

•  The  RCM  continues  to  emphasise  that  role-specific  training,  structured 
continued  professional  development  (CPD),  and  workforce  development  are 
essential to support safe home birth services. Without national guidance, there 
is  a  foreseeable  risk  of  inconsistent  care,  loss  of  midwife  competence  in 
specialist skills, and reduced opportunities for student learning. NHS England, 
as  the  responsible  organisation  for  service  delivery,  must  ensure  that  the 
forthcoming  policy  includes  clear  standards  for  staffing,  skill  maintenance, 
emergency preparedness, and escalation protocols to protect women, babies, 
and  the  workforce.  Once  developed,  NHS  England  must  hold  providers  to 
account for the robust and consistent implementation and ongoing adherence 
to the policy. 

A7 
 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.  

•  The  RCM  has  raised  concerns  with  NHS  England  and  the  Nursing  and 
Midwifery  Council  regarding  the  increasing  number  of  women  with  complex 
pregnancies and births requesting to give birth at home, in midwifery-led units, 
or without any medical or midwifery support at all. To ensure that women can 
make  informed  choices  safely  while  addressing  concerns  associated  with 
hospital-based  care,  maternity  services  must  have  sufficient  and  effective 
staffing, equipment and resources. 

•  We  remain  concerned  about  the  inappropriate  pressure  being  placed  on 
midwives  to  work  excessive  hours  on  a  regular  basis,  with  inadequate 
equipment and resources and the impact this has on safety. 

•  The  RCM  has  engaged  with  NHS  partners  to  emphasise  the  importance  of 
consistent risk assessment frameworks and professional guidance, supporting 
midwives  in  decision-making  and  escalation  and  the  safe  management  of 
complex case working with properly resourced multidisciplinary team. 

•  The  RCM  supports  and  promotes  professional  learning  through  member 
communications and resources, highlighting the importance of risk escalation 
and informed consent in line with existing RCM guidance such as  Care Outside 
Guidance (2022) and Standing up for High Standards (2022) and the Nursing 
and  Midwifery  Council  (2025)  Principles  for  supporting  women’s  choices  in 
maternity care. 

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. 

•  Evidence demonstrates that women receiving care from  midwives, educated 
and  regulated  to  a  high  standard,  experience  safer  outcomes  than  birthing 
without  professional  support,  and  that  midwifery-led  models  of  care  are 
associated with improved safety when appropriately resourced and governed 
(WHO,  2024).  Failure 
risks  continued 
inconsistency, skill dilution and preventable harm.   

to  provide  national  direction 

•  Homebirth services are nationally commissioned as part of maternity services 
and should be in accordance with NICE guidance. However, the RCM has long 
been aware through feedback from our branches and members that homebirth 
services are frequently suspended due to a lack of safe staffing. This is further 
reinforced by women's feedback in research and media that their choices for 
labour and birth are influenced by an expectation that NHS homebirth services 
may not be available when they need them.  

A8 
 •  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. 

•  The  RCM  advocates  for  nationally  commissioned  home  birth  services, 
underpinned by safe and sustainable staffing models, as a means of enabling 
genuine informed choice and supporting women’s legal rights to choose to give 
birth at home, while ensuring that this choice is offered in a way that is safe 
and proportionate and ethically sound for midwives working time. 

•  National  guidance  would  clarify  system  accountability,  reduce  unwarranted 
variation, and support midwives to gain and maintain the skills and experience 
required  to  provide  safe  home  birth  care  through  structured  pre-registration 
education and post-registration practice. It would allow midwives to work in a 
properly resourced system which allows them the time to provide the level of 
care women and babies need and want.  

4. Even though there is a very small risk of death, this is not something which 
is discussed with women particularly in relation to maternal death, even if the 
woman has a recognised risk such as a post-partum haemorrhage. There is no 
guidance to ensure the risk of death to both mother and baby is discussed with 
any woman considering a home birth irrespective of being considered high or 
low risk.  

•  The RCM acknowledges that national consistency in discussing risk, including 
rare  outcomes,  requires  system-level  guidance.  The  RCM  continues  to 
advocate for clear national frameworks to support consistent, high-quality risk 
communication  across  all  maternity  settings,  with  dedicated  funding  and 
protected time for implementation. 

•  While maternal  and  neonatal  death  is rare,  it remains a potential  risk  in  any 
birth setting. The RCM supports women in making informed choices based on 
clear, balanced, and individualised discussions of risks and benefits relevant to 
their personal circumstances, rather than framing risk solely by place of birth. 

•  Through  professional  guidance  and  member  communications,  the  RCM 
emphasises the importance of personalised care, informed consent and shared 
decision-making (2022), including discussion of material risks appropriate to a 
woman’s  clinical  history,  identified  risk  factors  and  planned  place  of  birth.  
Midwives  and  maternity  professionals  are  responsible  for  ensuring  that 
information  is  presented  in  a  way  that  supports  understanding  and  decision 
making without causing unnecessary alarm but often tell us they do not have 
adequate time to do this effectively. 

•  Your report highlights the failure to refer to a senior midwife for a more detailed 
discussion  with  Jennifer.  The  translation  of  evidence  to  support  informed 
choice  requires  skill  and  experience,  this  is  particularly  evident  in  situations 
where there is no national guidance and limited or a lack of evidence. The RCM 

A9 
 
 continues  to  call  on  maternity  services  across  the  UK  to  embed  consultant 
midwife roles to lead the delivery of high-quality personalised care for women 
choosing  birth  in  midwifery  led  settings  where  guidance  does  not  currently 
exist.  This  role  is  essential  in  its  ability  to  work  in  collaboration  with  the 
maternity and neonatal multi-disciplinary team and external to the service to 
plan and communicate the care provision needed.   

5. NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 
only refers to the potential risk of death to a baby. There is no mention in the 
guidance of risk to the mother. 

•  NICE are responsible for redevelopment of guidance to address maternal risk 
explicitly,  and  the  RCM  would  contribute  professional  expertise  through 
consultation processes as appropriate. 

 6.  Terminology  around  pregnancies  describes  them  as  ‘high’  or  ‘low  risk 
pregnancy’  and  leads  women  to  consider  that  pregnancy  encompasses  all 
stages  through  to  delivery  of  a  child.  Practice  does  not  personalise  or 
individualise  risk  so  women  can  fully  understand  what  the  level  of  risk  is  for 
them in actually being pregnant, or what the level of risk is for them in giving 
birth.  

The  RCM  has  raised  concerns  regarding  risk  communication  and  the  need  for 
personalised discussions with women, including through professional forums and the 
RCM Re:Birth project (2022). Approaches that support meaningful, individualised risk 
assessment  and  shared  decision-making  are  essential  to  ensure  that  women  can 
make informed choices based on their unique circumstances rather than broad risk 
categories. 

7.  In  order  to  maintain  their  skills,  there  is  no  set  number  of  deliveries  a 
community midwife must conduct following qualification. There is no mandated 
number of deliveries that any midwife (irrespective of the settings in which they 
are working) must complete once they have qualified as a midwife in order to 
maintain their registration. The level of experience of community midwives in 
conducting deliveries is not information routinely provided to women to inform 
their decision whether to have a homebirth.  

•  There is currently no mandated requirement for qualified midwives to conduct 
a  minimum  number  of  births  to  maintain  registration,  nor  would  such  a 
requirement be appropriate given the broad scope of midwifery practice beyond 
labour and birth. Education and training should be role-specific and aligned to 
the  responsibilities  of  the  midwife,  ensuring  that  learning  and  practice 
opportunities are relevant to the tasks they are expected to perform. 

•  The current service configuration impacts the learning opportunities of student 
midwives, limiting their ability to acquire the experience required to become fully 

A10 
 
 
 competent practitioners. Without appropriate experience, future midwives may 
enter  the  workforce  with  insufficient  exposure  to  home  births,  potentially 
undermining workforce capacity and safety. 

•  The RCM recognises that standards for education, registration, and revalidation 
fall within the remit of the Nursing and Midwifery Council (NMC). We continue 
to  advocate  for  policies  and  commissioning  arrangements  that  support 
midwives to maintain their competence and adhere to safe working standards 
that  protect them  from  working  long  hours  with  inadequate  rest  periods. The 
RCM works in partnership with the NMC to highlight the implications of current 
service  models  for  student  learning,  professional  development,  and  safe 
practice, through appropriate professional and policy channels. 

8.  No  bespoke  training  needs  analysis  has  been  conducted  focusing  on 
midwives practicing in home birth teams.  

•  Members  of  the  RCM  report  that  opportunities  for  continuing  professional 
development  (CPD)  are  frequently  limited,  often  due  to  workforce  pressures 
that  reduce  time  available  for  learning.  This  has  direct  impact  on  both 
supporting pre-registration student learning and role specific learning, such as 
midwives  attending  home  birth  and  therefore  has  implications  for  delivery  of 
safe, high-quality care. 

•  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. 

•  While standards for mandatory training and revalidation fall within the remit of 
NHS  England  and  the  Nursing  and  Midwifery  Council  (NMC),  the  RCM 
continues to advocate for workforce development approaches that recognise 
the unique skills, challenges, and demands associated with home birth care, 
and the necessity of protected time to deliver safe, evidence-based maternity 
services. 

•  Evidence demonstrates that midwifery-led care, including home birth, is safest 
when  midwives  have  structured  opportunities  to  maintain  and  develop  their 
skills. Failure to provide such opportunities represents a foreseeable systemic 
risk  that  must  be  addressed  through  national  guidance,  commissioning,  and 
workforce planning. 

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.  

•  The RCM recognises that responsibility for data collection and record keeping 

sits with NHS England.  

A11 
 
 10. The no national guidance on the model of staffing, training and experience 
for midwives providing home birth care. 

•  The  concerns  raised  in  the  report  highlight  unsafe  models  of  staffing  with 
homebirth  services  being  particularly  vulnerable  due  to  staffing  shortages.  
Inadequate staffing levels are further exacerbated by the implementation of on-
call systems to mitigate staffing shortfalls and represents a foreseeable risk to 
safe  service  delivery.  The  RCM  has  long  campaigned  for  safe  working 
standards  to  ensure  midwives  do  not  work  excessive  hours  and  receive 
adequate rest periods, yet evidence shows this is still not being achieved, with 
our  members  working  on  average  100,000  hours  of  unpaid  overtime  every 
week in 2024. The RCM remains concerned that it must continue to challenge 
the implementation of on-call systems and unsafe working conditions. These 
issues  are  being  addressed  through  both  local  negotiating  mechanisms  and 
industrial action mandates where necessary.   

•  The  RCM  has  stressed  that  restrictions  to  home  birth  services  arising  from 
staffing  pressures  may  unintentionally  limit  women’s  choices  and  could 
contribute to an increase in unregulated or unsupported birth settings, further 
heightening  safety  concerns. Addressing  workforce  sustainability  is  therefore 
critical  to  prevent  such  unintended  consequences,  as  outlined  in  the  RCM 
Reconfiguration of services position statement. 
In addition, the RCM has raised concerns that the suspension or reduction of 
home birth services due to staffing shortages, as already observed in multiple 
maternity units in England, presents a long-term risk to the maintenance of skills 
and expertise. This includes both undergraduate student education and post-
registration practice, with potential implications for the future workforce’s ability 
to deliver safe, competent care in community and home birth settings.   

• 

•  The RCM continues to lobby government and national bodies, drawing on the 
substantial body of evidence demonstrating the need for sustained investment 
in maternity staffing. This advocacy forms a core part of our political influencing 
work to support safe, effective, and sustainable maternity services and ensure 
that women can access high quality, evidence-based care in all settings. ‘Safe 
Staffing=  Safe  Care’  is  the  paramount  campaign  for  the  RCM  in  2026 
recognising that achieving safe staffing will: 

o  Ensure maternity services have the right staff in the right place with the 

right education and training; 

o  We have services that meet the needs of communities and the staff that 

work in them; 

o  And we build a midwifery profession that’s fit for the future. 

A12 
 
 
 
 Thank  you  again  for  raising  these  matters  with  the  RCM.  We  trust  this  response 
addresses  the  matters  raised  in  your  report.  Please  let  us  know  if  any  further 
information or clarification is required. 

Your sincerely 

CEO and Chief Midwife 
The Royal College of Midwives 

A13 
 References 

National  Institute  for  Health  and  Care  Excellence  (NICE).  Intrapartum  care  for 
healthy women and babies. NICE guideline [CG190]. London: NICE; 2023. Updated 
June 2025. 

National Institute for Health and Care Excellence (NICE). Fetal monitoring in labour. 
NICE guideline. London: NICE; 2025. 

Royal College of Midwives (RCM). Care outside guidance. London: RCM; 2022. 

Nursing and Midwifery Council (NMC). Principles for supporting women’s choices 
in maternity care. London: NMC; 2025. 

Royal College of Midwives (RCM). Standing up for high standards: Professional 
expectations of midwives. London: RCM; 2022. 

World Health Organization (WHO). Midwifery models of care: Evidence to support 
safe, quality maternity services. Geneva: WHO; 2024. 

Royal College of Midwives (RCM). Informed Decision Making. London: RCM; 2022. 

Royal College of Midwives (RCM). Re:Birth project. London: RCM; 2022. 

Royal College of Midwives (RCM). Reconfigurations in maternity services. London: 
RCM; 2023 

A14

Joanne Kersley 
His Majesty’s Senior Coroner Area for the Coroner area of Manchester North  
HM Coroner's Officer 
HM Coroner’s Court 
Floors 2 & 3, Newgate House,  
Newgate,  
Rochdale, OL16 1AT 

23 December 2025 

Re: Jennifer and Agnes Cahill 

Dear Ms Kersley 

Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the 
death of Jennifer Cahill and Baby Agnes Cahill received on 5 November 2025. 

The loss of a young woman and her baby is a devastating tragedy for the family and all concerned. 
We would like to begin by extending our deepest and heartfelt condolences to Jennifer and Agnes’s 
family for their deep loss.  

This response has been developed following input from members of the Royal College of 
Obstetricians and Gynaecologists (RCOG) Patient Safety Committee and Senior Officers of the 
College.  

We recognise and respect the narrative conclusion from the inquest. The medical cause of the death  

Jennifer: 

 1a) Multiorgan failure with disseminated intravascular coagulation  
 1b) Cardiac arrest due to post-partum haemorrhage 
 1c) Perineal tear and atony during term delivery 

 Agnes:  

1a multi-organ insult following hypoxic ischaemic encephalopathy  
1b. Cord compression and meconium aspiration syndrome leading to pulmonary hypertension 

The MATTERS OF CONCERN are as follows:  

1.  There is no national guidance in respect of home births. Specifically, robust evidenced based 

guidance on home birth care, similar to that which is in place for intrapartum care in a hospital 
setting. 

The NICE Guideline on intrapartum care (2025)1 makes recommendations on place of birth. It 
includes guidance on recommended place of birth for women with previous obstetric complications, 
including the advice that those with a previous history of postpartum haemorrhage should plan birth 
1 

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 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 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.  

The RCOG, alongside our partner organisations in maternity (DHSC/NHSE/RCM) will support NICE  in 
their ongoing work to ensure that the best evidence-based guidance is available to support all 
aspects of women's maternity journey.  

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.      

The lack of national guidance in this landscape has also been highlighted in a briefing from the 
Maternity and Newborn safety Investigations (MNSI) on Birthing outside of guidance (2025)3. The 
RCOG has recently commissioned a Good Practice Paper on supporting women requesting care 
outside of guidance. This is in the early stages of development. This document, in part, will describe 
the role of obstetricians in providing care to these women as part of the wider team of healthcare 
professionals. It will support existing guidance from the Royal College of Midwives (RCM) on Caring 
for women seeking choices that fall outside of guidance (2022) 4 and guidance from the Nursing and 
Midwifery Council (NMC) on the Principles for supporting women’s choices in maternity care (2025)5.  

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.  

NHSE/DHSC is best positioned to address this point.  

4.  Even though there is a very small risk of death, this is not something which is discussed with 
women particularly in relation to maternal death, even if the woman has a recognised risk 
such as a post-partum haemorrhage. There is no guidance to ensure the risk of death to both 
mother and baby is discussed with any woman considering a home birth irrespective of being 
considered high or low risk. 

Women do not formally give consent for planned vaginal birth, regardless of their individual risk or 
the place they plan to birth, mostly because planned spontaneous vaginal birth is a physiological 
process, rather than an intervention (such as an assisted vaginal birth or caesarean birth). However, 
there are opportunities throughout pregnancy for women to have discussions around their birth 

2 

A33 
 
 
 
 
 
 
 
 
 
 
 
 
 plan and what it may mean for them. All women and birthing people should be supported by their 
maternity team in developing a Personalised Care and Support Plan that evolves throughout their 
pregnancy and birth, and which should be reviewed and modified, especially when risk factors 
change. This includes an individualised risk assessment as well as providing evidence-based 
information about birth choices. 

In complex situations, which may include the choice to have care outside of guidelines, obstetric as 
well as midwifery input should be provided and this may, depending on the circumstances, 
include evidence informed discussions about the most severe risk6. The RCOG recognises the 
importance of all discussions with women being undertaken in a manner to ensure the information 
is understood and does not serve to cause fear or take away choice, but to engender a position of 
true, informed choice with documentation to support further discussion, understanding of what was 
discussed and the outcome plan6.   

5.  NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 only refers to the 
potential risk of death to a baby.  There is no mention in the guidance of risk to the mother. 

NICE is best positioned to address this point.  

6.  Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ and leads 
women to consider that pregnancy encompasses all stages through to delivery of a child.  
Practice does not personalise or individualise risk so women can fully understand what the 
level of risk is for them in actually being pregnant, or what the level of risk is for them in giving 
birth.   

The RCOG supports obstetricians to provide women with information that enables them to make 
informed choices about their care in pregnancy, birth and the postnatal period. These conversations 
should be ongoing. As a result, the expectation is that each woman is provided with the right 
information, provided in an appropriate manner, in order for her to understand the level of risk for 
her and her baby in the antenatal period, during the birth and during the postnatal period.  

7. 

In order to maintain their skills, there is no set number of deliveries a community midwife 
must conduct following qualification.  There is no mandated number of deliveries that any 
midwife (irrespective of the settings in which they are working) must complete once they have 
qualified as a midwife in order to maintain their registration.  The level of experience of 
community midwives in conducting deliveries is not information routinely provided to women 
to inform their decision whether to have a homebirth.  

The RCM/NMC is best positioned to address this point. 

8.  No bespoke training needs analysis has been conducted focusing on midwives practicing in 

home birth teams. 

The RCM/NMC is best positioned to address this point. 

3 

A34 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 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.  

NHSE/DHSC is best positioned to address this point.  

10. There is no national guidance on the model of staffing, training and experience for midwives 

providing home birth care. 

The RCM/NMC is best positioned to address this point. 

Thank you for raising these matters with the RCOG. I would like to again express our deepest 
condolences to Jennifer and Agnes’s family for their devastating loss.  

Yours sincerely, 

Chief Executive 
CEO Royal College of Obstetricians and Gynaecologists 

References  

1.  Intrapartum care, NICE guideline (NG235) 2025 Overview | Intrapartum care | 

Guidance | NICE  

2.  Fetal monitoring in labour, NICE guideline (NG229) 2025 Overview | Fetal 

monitoring in labour | Guidance | NICE  
3.  Birthing outside of guidance, MNSI 2025 

140225_Briefing_Birth_Outside_of_Guidance__v2_Addendum_MASTER_editable.pd
f 

4.  Supporting women seeking care outside guidance, RCM 2022 Supporting women 

seeking care outside guidance - Royal College of Midwives 

5.  Principles for supporting women's choices in maternity care, NMC 2025 Principles 
for supporting women's choices in maternity care - The Nursing and Midwifery 
Council 

6.  National Maternity Review- Better Births, NHSE 2016, national-maternity-review-

report.pdf  

7.  Birthplace in England Research Programme, NPEU/SHEER 2011Birthplace in England 

Research Programme | SHEER | NPEU  

4 

A35