Jennifer Cahill and Agnes Cahill

Dear Coroner, 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:

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

24 December 2025 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.

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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.

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.

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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 A22

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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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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.

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.

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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 to provide national direction risks continued inconsistency, skill dilution and preventable harm.
• 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.

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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

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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

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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 A26

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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 A27

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(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 A28

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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 A29

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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.

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

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,

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