Matilda Pomfret-Thomas

Date of report	15 Jan 2026
Reference	2026-0025
Deceased	Matilda Pomfret-Thomas
Coroner	Henry Charles
Coroner area	Hampshire, Portsmouth Southampton
Category	Child Death (from 2015)
Source	judiciary.uk record · original PDF
Responses published	4

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Regulation 28: REPORT TO PREVENT FUTURE DEATHS

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:

1 Department for Health and Social Care (PFDs/Reg28)
2 NICE (National Institute for Health and Care Excellence)
3 Nursing and Midwifery Council

CORONER

I am Henry CHARLES, HM Assistant Coroner for the coroner area of Hampshire, Portsmouth
and Southampton

CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

INVESTIGATION and INQUEST

On 15 November 2023 I commenced an investigation into the death of Matilda Gwen
POMFRET-THOMAS aged 15 Days. The investigation concluded at the end of the inquest on
04 December 2025. The medical cause of death was Hypoxic Ischaemic Encephalopathy.
The narrative conclusion of the inquest was as follows:

Matilda Pomfret Thomas sadly died on 13th November 2023 at Naomi House and Jacks
Place, Stockbridge Roads, Sutton Scotney, Winchester, Hampshire by reason of Hypoxic
Ischaemic Encephalopathy. She was 15 days old at the date of her death. She was born on
29th October 2023 at Queen Alexandra Hospital following a difficult labour at home. The
Hypoxic Ischaemic Encephalopathy had developed over a period of hours. Meconium had
been observed, decelerations were later observed.
following those complications becoming apparent until 12.13 on the 29th October 2023.
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 29th October 2023 and there was prompt
midwife attendance. An initial and appropriate offer at 7.19 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.

was not taken to hospital

CIRCUMSTANCES OF THE DEATH

Please see the narrative conclusion.
The birth of the family’s first child had been traumatic and, for the birth of their second
child, they were focussed on achieving a different birth experience and elected to use a
doula to provide them with support at a home birth. 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. Signs of fetal distress developed but the mother was not
immediately transferred to hospital. A difficult atmosphere had developed, the midwives
felt access was being restricted by the doula: I found that she did not actively discourage

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

midwife access but that she was seen as, in effect, a buffer by members of the midwifery
team. The doula was following the birth plan. The doula was supporting the parents per
the birth plan, and this appears to have been perceived as grounds for hope that a home
birth was still possible.

CORONER’S CONCERNS

During the course of the investigation my inquiries revealed matters giving rise to concern.
In my opinion there is a risk that future deaths could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:
(brief summary of matters of concern)

Doulas provide continuity of care and give emotional, informational and practical support
throughout pregnancy, labour and after the birth of a baby: those words come from Doula
UK’s website. 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. Doula UK have put in place membership requirements, training offers and much
guidance, but the role of a doula is clearly diffuse in practical terms and capable of multiple
understandings not just by doulas but their clients and midwives.

It appears that doulas have been increasingly used and increasingly offer services - as here
- on a paid basis.

As MNSI (Maternity & Newborn Safety Investigations - formerly HSIB) put it in their report
into this birth, “MNSI acknowledges that there is no regulation of doula care or any
guidance on how the two services interact with each other. 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.”

MNSI have identified 12 cases in which there was evidence that 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.

There was evidence given at the inquest by experienced midwifery professionals
highlighting that provision of guidance would be helpful for all involved with a birth at which
a doula was present.

The issues of doula registration, regulation and training are therefore points of concern I
would commend for review.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you (and/or
your organisation) have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by March 06, 2026. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

Queen Alexandra Hospital Legal Department

Doula UK

Maternity and Newborn Safety Investigations (MNSI)

I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.

I may also send a copy of your response to any person who I believe may find it useful or
of interest.

The Chief Coroner may publish either or both in a complete or redacted or summary form.
They may send a copy of this report to any person who they believe may find it useful or of
interest.

You may make representations to me, the coroner, at the time of your response about the
release or the publication of your response by the Chief Coroner.

Dated: 15/01/2026

Henry CHARLES
HM Assistant Coroner for
Hampshire, Portsmouth and Southampton

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

Responses

4 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Department of Health and Social Care (PDF)

Minister of State for Health (Secondary Care)

39 Victoria Street
London
SW1H 0EU

04 March 2026

HM Coroner Henry Charles
Coroner’s Office
Castle Hill
Winchester
Hampshire
SO23 8UL
01962 667884

Dear Mr Charles,

Thank you for the Regulation 28 report of 15th January 2026 sent to the Secretary of State /
the Department of Health and Social Care about the death of Matilda Gwen Pomfret-
Thomas. I am replying as the Minister with responsibility for secondary care.

Firstly, I would like to say how saddened I was to read of the circumstances of Matilda’s
death and I offer my sincere condolences to their family and loved ones. The circumstances
your report describes are concerning and I am grateful to you for bringing these matters to
my attention.

The report raises concerns over the absence of formal regulation, registration, and training
for doulas, highlighting risks to patient safety where unregulated birth support roles are
involved. The report suggests a lack of regulation & standardised training creates variability
in knowledge, capability, and adherence to safe practice.

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

There is no legal requirement doulas to have any training or qualifications. The role is
usually performed by people from a wide variety of backgrounds, who are not subject to
oversight by the Nursing and Midwifery Council (NMC) or General Medical Council (GMC),
or other professional regulatory oversight.

However, if the role of a doula is carried out by a regulated healthcare professional, they
would be subject to regulatory oversight by the relevant regulator. Even if a healthcare
professional is acting in a personal role, they cannot ‘opt out’ of their core duties and
responsibilities.

Any organisation that holds a register for doulas is an independent, representative body
and as such, they do not fall under Government oversight. Therefore, any decisions about
the practice requirements for the professions they represent are a matter for those
organisations and their members.

I note that your report has also been sent to the Nursing and Midwifery Council (NMC) as
the independent regulator of midwives in the UK.

I understand that the NMC’s ‘Principles for supporting women's choices in maternity care’
includes information on the role of doulas, which were developed to support midwives and
organisations providing personalised care for women during pregnancy, birth and the
postnatal period.

The NMC has also worked with Doula UK to launch a video resource intended to clarify
the distinct roles that midwives and doulas play for women and families, in addition to
setting out how the professions can work together to support positive maternity
experiences. The maternity principles and video are available at:
https://www.nmc.org.uk/standards/guidance/principles-for-supporting-womens-choices-in-
maternity-care/.

The National Institute for Heath and Care Excellence (NICE) publishes clinical guidance to
improve health and social care, including the Guideline on Intrapartum care (2023). That
guidance covers 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.

The NHS supports women having someone with them during labour and birth when they
choose it. This is often their life partner, but equally may be another relative, friend or a
doula.

The Nursing and Midwifery Council (NMC) Standards of proficiency for midwives (2019)
expects midwives to be able to work with women, their partners and families, and by
extension therefore with a doula.

That said, Doulas must not undertake midwifery or other clinical care. Given the
unregulated nature of the Doula role, and that the support they give during labour and birth
carries no additional status than for anyone else, NHS England will not be producing
guidance for midwives’ interactions with doulas.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Yours sincerely,

MINISTER OF STATE FOR HEALTH

Response from Developing Doulas (PDF)

Voluntary Submission in Response to Prevention of Future Deaths Report (Ref: 2026-
0025)
Re: Matilda Pomfret-Thomas
Dated 18 February 2026

To: HM Assistant Coroner Henry Charles
Hampshire, Portsmouth and Southampton

I write in a personal and professional capacity as a practising doula of fourteen years and
as a Doula Training Course Facilitator and Co-Owner of Developing Doulas.

I am not a statutory recipient of the Regulation 28 Report and therefore am not responding
under Regulation 29 of the Coroners (Investigations) Regulations 2013. However, given that
the report raises concerns regarding the role and presence of doulas, I consider it
important, in the interests of balanced learning and prevention, to provide the following
voluntary submission.

This response addresses the Prevention of Future Deaths (PFDR) report speciﬁcally in
relation to its references to the presence and role of a doula during this birth, and the
suggestion that this presence “negatively impact[ed] upon the e(cid:431)ective provision of
midwifery services in terms of building a rapport conducive to e(cid:431)ective advice and care 
being given.”

The PFDR records that the doula did not actively discourage midwife access, that she was
supporting the parents in accordance with the agreed birth plan, and that she was
nonetheless perceived by members of the midwifery team as, “in e(cid:431)ect, a bu(cid:431)er.” It further
suggests that this support was perceived as grounds for hope that a home birth remained
possible.

This description highlights the importance of clearly distinguishing between perception
and responsibility. As described in the report, the doula’s actions were consistent with a
non-clinical support role: supporting the parents’ stated wishes and birth plan, without
restricting access, providing clinical advice, or exercising authority over decision-making. A
perception of her presence as a “bu(cid:431)er” reﬂects the experience of the clinical team, rather 
than evidence of obstruction or causal action on the part of the doula.

Responsibility for building and maintaining a rapport that enables the delivery of e(cid:431)ective 
clinical advice and care rests with the clinician who holds clinical responsibility. This
responsibility is non-delegable and applies regardless of who else is present to support the
family. Where clinical concern arises - particularly in the context of deteriorating fetal
wellbeing - the duty to communicate risk clearly, to support informed decision-making, and
to escalate care appropriately remains with the healthcare professionals involved.

 The background of a previous traumatic birth is, I believe, highly relevant in understanding
why this family elected for a home birth and chose to engage a doula. Many families who
have experienced birth trauma seek additional non-clinical support in order to feel safer
and more able to engage with care. The presence of such support should not impede
e(cid:431)ective communication of clinical concern or timely escalation. Support for a birth plan, 
or expressions of hope for a particular outcome, should not be understood as a barrier to
clinical leadership or decision-making.

If clinicians experience di(cid:431)iculty carrying out their role e(cid:431)ectively when a doula is present, 
this points to a need for improved training, conﬁdence, and support in working alongside
non-clinical supporters, rather than indicating an inherent risk associated with the
presence of a doula. It is also relevant to consider whether similar perceptions would arise
if the supporter present were a partner, parent, sibling, or other family member - all of
whom are commonly present at births and are not typically characterised as barriers to
care.

Doulas a(cid:431)iliated to Doula UK and other membership organisations operate within
established professional guidelines and codes of conduct that emphasise clear
boundaries, respect for clinical roles, and support for informed choice. The doula
profession is unregulated not because of an absence of standards, but because it is a non-
clinical support role. In this respect, it is comparable to other support professions such as
counselling and advocacy, where practice is governed by professional ethics rather than
statutory regulation.

From a prevention perspective, learning would be better directed toward strengthening
clinicians’ skills in trauma informed care, communication of risk, and the maintenance of
clear clinical responsibility in complex and emotionally charged situations. Care should be
taken to avoid attributing causal signiﬁcance to non-clinical supporters in a way that risks
obscuring professional responsibility or diverting attention from the systemic and
professional learning that PFDRs are intended to promote.

Furthermore, while the MNSI report referenced within the PFDR is relevant, it is important
to distinguish the nature of the evidence it contains. The twelve references to doulas
associated with poor outcomes reﬂect the perceptions and reporting of healthcare
providers only. MNSI has conﬁrmed that, in these cases, neither the families a(cid:431)ected by 
the outcomes nor the doulas involved were invited to provide their perspectives.

It is not appropriate to form conclusions or develop e(cid:431)ective or strategic responses on the 
basis of evidence that is so heavily weighted toward a single source. While it is entirely
possible that, in some cases, a doula may have made a mistake or inﬂuenced a decision, it

 is not possible to establish this as fact where information has been collated solely from
one professional perspective.

The evidence supporting the beneﬁts of doula care is well established, as is the
importance of doulas remaining independent from the maternity system.

In an underfunded, under resourced, and highly litigated system, this independence can
sometimes give rise to resentment, misunderstanding, or projection. These systemic
pressures do not negate the value of doula support, but they do highlight the need for
improved shared understanding.

The most constructive way forward, in my own well-researched opinion - is through better
training for healthcare professionals to understand why families seek doula support, to feel
conﬁdent and clear about their own roles and responsibilities, and to understand the role,
boundaries, and purpose of the doula. This includes recognising where roles di(cid:431)er, where 
they intersect, and how they can collaborate e(cid:431)ectively in the interests of safety and 
family centred care.

The MNSI itself has acknowledged the importance of improved shared understanding
between healthcare professionals and doulas. Meaningful prevention of future deaths
depends on balanced learning, clear accountability, and a commitment to strengthening
systems and relationships, rather than attributing undue causal weight to the presence of
non-clinical support.

I also wish to add this context from professional experience. I have worked as a doula for
fourteen years, and the challenges highlighted in this report are, regrettably, not new. Over
that time, I have witnessed many more examples of e(cid:431)ective, collaborative working
between doulas and healthcare professionals than instances of defensiveness or hostility
within birthing environments.

However, I have also experienced situations in which I have been wrongly accused of
inﬂuencing decision-making or providing clinical advice, particularly where healthcare
professionals have felt a(cid:431)ronted or insu(cid:431)iciently conﬁdent to include a doula as part of the
wider care team. There is currently a lack of clear processes for addressing such situations
when they arise, within most local trusts, and as a result doulas are often left to live with
misunderstanding and misrepresentation without recourse.

These dynamics can have wider consequences. They can further harm what may already
be a fragile relationship between a service user and the maternity system, and can
contribute to a deepening loss of trust when families experience rejection of a doula they
have chosen and employed to support them.

 For reports intended to prevent future harm, it is essential that they accurately represent
the underlying issues at play. Without doing so, there is a risk that learning is misdirected,
and that opportunities to address the real systemic and relational challenges - rather than
their symptoms - are missed.

It is also important to acknowledge the context in which midwives practise. Midwives
already carry a heavy burden of responsibility and the weight of potential legal recourse.
Without appropriate understanding of the doula role, of independent advocacy, and of
trauma aware responses to families who have chosen to employ a doula, it is
understandable that some midwives may experience fear or anxiety about a doula’s
presence.

Women and birthing people/families arrive in maternity services as whole people, with
complex histories, values, and lived experiences long before pregnancy and birth.

The vast majority of doulas support informed decision making, which may include
decisions to decline certain interventions. In most cases, a desire to decline intervention
exists prior to the involvement of a doula, rather than being created by it.

When families experience a lack of autonomy within maternity services, this is frequently
described as infantilising and disempowering.

Independent support is often sought precisely because families wish to engage more fully,
not less, in decision making about their care. Understanding this motivation is essential if
maternity services are to respond in ways that build trust, rather than deepen fear or
division.

In conclusion, meaningful prevention of future harm depends on accurate representation,
shared understanding, and clarity of roles and responsibilities. Where di(cid:431)iculties arise in 
births involving doulas, learning should focus on strengthening trauma-informed
communication, conﬁdence in clinical leadership, and collaborative working with non-
clinical supporters.

Attributing disproportionate causal weight to the presence of a doula risks obscuring these
core issues and diverting attention from the systemic improvements that are necessary to
support safe, respectful, and truly family-centred maternity care. These themes are
explored further in Michelle Quashie’s article Safety: Self-Determined and Human Rights
Compliant in The Practising Midwife (available via All4Maternity), and in Milly Morris’s
dissertation Doulas and Midwives: A Powerful Alliance, both of which o(cid:431)er valuable context 
for this discussion.

Yours sincerely,

 Doula | Doula Training Course Facilitator and Co-Owner at Developing Doulas

Response from National Institute for Health and Care Excellence (PDF)

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

20 February 2025 

Mr Henry Charles 
HM Assistant Coroner for Hampshire, Portsmouth and Southampton 
Coroner's Court 
1 Guildhall Square 
Portsmouth 
PO1 2GJ 

Dear Mr Charles, 

Re: Regulation 28 Prevention of Future Deaths Report in respect of Matilda Pomfret-
Thomas 

I write in response to your regulation 28 report, dated 15 January 2026, regarding the very sad 
death of Matilda Pomfret-Thomas. I would like to express my sincere condolences to Matilda’s 
family. 

We have reflected on the circumstances surrounding Matilda’s death and senior clinical 
advisers within our patient safety team have reviewed the concerns raised in your report, which 
we note has also been sent to the Nursing and Midwifery Council (NMC).   

The registration, regulation and training of Doulas is not the responsibility of NICE and is better 
addressed by the Nursing and Midwifery Council (NMC), Royal College of Midwives (RCM) and 
the Royal College of Obstetricians and Gynaecologists (RCOG). 

I hope that this clarification is helpful and I would like to reiterate my sincere condolences to 
Matilda’s family.  

Yours sincerely, 

Chief Executive 

 CBE MD FRCS FRCEM 

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

Response from Nursing and Midwifery Council (PDF)

From the Chief Executive and Registrar

Henry Charles
HM Assistant Coroner for Hampshire, Portsmouth and Southampton

10 March 2026

Dear Sir

Regulation 28 Prevention of Future Deaths report dated 15 January 2026 in relation to Matilda
Gwen Pomfret-Thomas

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

Your report identiﬁes two speciﬁc areas where you consider action is necessary in respect of the
role of doulas and the support they provide through pregnancy, labour and after the birth of a
baby. 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, whilst recognising that some of the issues
raised sit outside our remit.

Our vision is to provide safe and effective midwifery education and practice across the four
countries of the UK. I set out below the steps we will be taking, and have already taken, to the
address some of the issues in relation to the relationship between midwifery professionals and
doulas (or other ‘unregulated professionals’) highlighted by your investigation.

Actions arising from your report

1. There was evidence given at the inquest by experienced midwifery professionals

highlighting that provision of guidance would be helpful for all involved with a birth at
which a doula was present.

Our role is to protect the public and maintain conﬁdence in the nursing and midwifery professions.
We support 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 proﬁciency for midwives, which specify the knowledge,
understanding and skills that midwives must demonstrate at the point of qualiﬁcation and after
registration, when caring for women, newborn infants, partners and families throughout the
maternity journey and across all care settings.

Doulas are not a regulated profession and do not fall within the remit of the Nursing and Midwifery
Council. We therefore cannot set standards of training or produce guidance on the role of doulas
and other unregistered birth workers. However, as the regulator of midwives we will continue
working with others to provide information which supports both the public’s and
professionals’ understanding of these different roles and the standards of care people should
expect from registered midwives.

Action taken to support the role of midwives

Through our regulation of midwifery professionals, and our ongoing relationships with senior
midwifery professionals across the four nations of the United Kingdom, we have already identiﬁed
some of the issues that may arise where women choose to engage the services of unregulated birth
support professionals, instead of or in addition to registered midwives.

In August 2025, we launched our “Principles for supporting women's choices in maternity
care” webinar, with supporting frequently asked questions from our launch webinar factsheet.
This all sets out a series of principles that have been developed to support midwives and
organisations providing personalised care for women during pregnancy, birth and the postnatal
period, wherever the care takes place. We have addressed the following points:

• Doulas are not regulated practitioners

• Doulas and other birth workers may have a range of names and titles, such as

‘birthkeeper’, ‘birthworker’, and ‘mother’s helper’, for example. In addition, some may have
formerly practised as midwives but are no longer registered.

• The role of doulas and other non-registered birth workers is to provide psychological and

social support but they are not there to provide midwifery care and advice which is the role
of a registered midwife.

The NMC has also worked with Doula UK to launch a video resource intended to clarify the distinct
roles that midwives and doulas play for women and families, in addition to setting out how the
professions can work together to support positive maternity experiences. The maternity principles
and video are available at: https://www.nmc.org.uk/standards/guidance/principles-for-supporting-
womens-choices-in-maternity-care/.

2. The issues of doula registration, regulation and training are therefore points of concern I

would commend for review.

We are not taking any action in respect of the issue of doula registration, regulation and training as
this is beyond the remit of the Nursing and Midwifery Council and is a matter for government policy.

Where we receive evidence of any concerns that may be relevant to public safety, we may decide to
refer matters to the police or other appropriate authorities for further investigation, particularly
where there is evidence of a poor outcome. We will raise this report at the next meeting of the
Maternity Regulation Oversight Group (MROG), an internal group that meets regularly to oversee
our regulatory response to concerns raised. The next meeting is on 11 March.

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.

Once again, I would like to offer my condolences to Matilda’s family for their tragic loss.

Yours faithfully

Chief Executive and Registrar

The report

Responses

Related reports

Other reports by Henry Charles

More reports categorised “Child Death (from 2015)”

Track Child Death (from 2015)