“That Phoenix’ death was and remains utterly devastating for his parents is unsurprising”

The coroner’s concerns

That Phoenix’ death was and remains utterly devastating for his parents is unsurprising. However, it was clear at inquest that it was also deeply shocking for those trying to care for him and his mum. Events were outside the experience of several of the healthcare professionals involved. I heard at inquest that new national maternity guidance is to be published at the end of the month. This will include within it revised advice for paramedics faced with an unplanned home delivery such as this one to transport to hospital even if birth is imminent. I was assured at inquest that the advice will quickly be disseminated. Had I not been given this information, I would have made a prevention of future deaths report to the ambulance service. It is of course of the utmost importance that hospital clinicians and ambulance clinicians have the same understanding of how a patient in any given situation should be treated, and I have copied this report to the London Ambulance Service (LAS). The reason I make a report to the Homerton, is because it seemed to me at inquest that there were two matters that had not yet been resolved. i) At inquest, there was not a shared understanding among the clinicians within the trust about how such a situation should be approached. The obstetricians were clear that, given her very high risk status, Phoenix’ mum needed to come in to hospital as soon as she showed the first signs of labour. And even if she had started to deliver, she could still only be treated effectively and Phoenix given the best chance of a good outcome in hospital. 2 However, some of the midwives felt strongly that, when Phoenix’ dad could see the baby’s leg emerge, they should have been allowed to go out to the home to give whatever assistance they could. All the clinicians need have the same understanding of the correct protocol. ii) A related point is that, before Phoenix was born, some of the midwives felt that their views of what should happen in the event of precipitous labour had not been taken seriously. If they are to be effective in their role, and if necessary to understand why a protocol does fully reflect their feelings and views, the midwives’ ability to communicate with senior management needs to be enhanced. If the team as a whole is to move forward in a way that provides the best possible care for women in labour and their babies, questions and differing opinions need to be in some way acknowledged and dealt with before the correct protocol can be embedded.

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, 2023-0246

Added to Minute Book

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