“following the inquest into Emilia’s death were as follows: 1”

The coroner’s concerns

following the inquest into Emilia’s death were as follows: 1. I am concerned that the two midwives who attended Emilia’s mother at home had limited experience of home births. One was a newly-qualified midwife who actually had 1 more experience in home births than the other midwife; despite decades of midwifery experience she had never attended a home birth before. I heard evidence that there is no specific regulatory requirement regarding midwifery experience at home births and that training to become a midwife requires attendance at 40 births of unspecified type. During the inquest it was set out that home births occur relatively infrequently and that it can be difficult to ensure involvement in such births during training. I also heard that some midwives tend to focus on specific areas of practice, such as low-risk or high-risk births and that their experience in other areas can therefore be limited. This is despite the potential need for any midwife to attend low-risk births and the regulatory requirement that midwives ensure competency in all areas of practice. I asked the hospital Trust involved for information as to how they ensure that midwives have appropriate experience in home birthing. They have set out as follows: The lead midwife has previous experience (gained knowledge and skills through direct observation and participation) of attending and facilitating a home birth or birth in a low risk setting The lead midwife normally works in a low risk birth setting i.e Community midwife or Bluebell birth centre midwife The lead midwife is competent and up to date with their mandatory training within a home birth or low risk birth setting thus demonstrating the knowledge and skills required. However, the concern remains that there is seemingly no specific regulatory requirement for training or ongoing exposure to areas of practice that midwives may encounter, in particular the unique issues that can arise during home births. 6 ACTION COULD BE TAKEN In my opinion action could be taken to prevent future deaths and I believe that the addressees have the power to take such action.

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, 2023-0166

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0