“(brief summary of matters of concern) 1”
Dated 27 Jan 2026, from the coroner for Cheshire. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 24 Mar 2026.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated27 Jan 2026
- Deadline24 Mar 2026
- Published on judiciary.uk29 Jan 2026
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| NHS England | Response publishedPublished on judiciary.uk in January 2026. |
| National Institute for Health and Care ExcellenceNamed in the report as “National Institution for health and care excellence” | Response publishedPublished on judiciary.uk in January 2026. |
| Department of Health and Social CareNamed in the report as “Department for Health and Social Care” | Response publishedPublished on judiciary.uk in January 2026. |
The coroner’s concerns
(brief summary of matters of concern) 1. There is no national guidance in respect of home births and in particular the model of care. Linked to this, there is therefore no guidance on: a. The training that a midwife should undergo to ensure they are competent to manage a home birth, given the inherent risks involved when there is no hospital team behind you in an emergency. b. The number of deliveries a midwife should have done in a hospital setting before being able to safely manage a home birth and/ or the number of deliveries a community midwife should be involved in to maintain their skills. c. The threshold for transfer to hospital. d. Safe staffing and equipment levels, without which the service should be suspended. e. The supervision which should be provided during a home birth, for example through a midwife in the hospital accessing the notes. f. A system for back-up should electronic systems fail i.e. whether paper notes should be provided as a routine. g. Information which should be provided to expectant parents around the risks of home birth/ the experience of the team to enable them to make an informed choice. 2. There is no national or local collection of data around home births such as number resulting in transfer to hospital, number involving injury to mother or baby. Such data would allow expectant parents to make an informed choice as to the risks of a home birth.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2026-0042
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use