Coroner Warns Unregulated Doulas Can Endanger Home Births After Baby's Death

A coroner’s prevention of future deaths report, released 21 January 2026, warns that doulas can impede midwives during births. The case centers on Matilda Pomfret‑Thomas, 15‑day‑old, who died on 13 November 2023 after suffering hypoxic‑ischaemic encephalopathy (HIE) caused by oxygen deprivation during labor. Her parents had chosen a home birth following a traumatic hospital delivery of their first child. During labor, a doula present—described by assistant coroner Henry Charles as negatively impacting midwife advice—failed to act on early signs of meconium passage and fetal heart‑rate decelerations. The baby was transferred to hospital only at 12:13 pm, too late to prevent death. The report cites 12 prior cases where doulas worked outside their defined role, and calls for review of registration, regulation and training. Findings were sent to the Department of Health, the Nursing and Midwifery Council and Doula UK.