Urgent review ordered after deaths in fragile maternity services

NHS England has ordered trusts to “urgently” review their home birth services, it has emerged – as an HSJ  investigation reveals widespread fragility and safety risks.

Chief midwifery officer Kate Brintworth wrote to trust and integrated care board CEOs late last year after “gross failures” were identified in the care of Jennifer and Agnes Cahill during a home birth under the care of Manchester University Foundation Trust in 2024.

Ms Cahill died shortly after suffering a haemorrhage during labour, while baby Agnes had the umbilical cord wrapped around her neck and was not breathing when she was delivered.

Coroner Joanne Kearsley identified serious failures by two inexperienced community midwives, and  a subsequent prevention of future deaths report warned of a lack of national guidance on staffing, training and experience for midwives attending home births.

NHSE’s letter, which was sent last year but has not been made public, comes as HSJ analysis shows multiple coroners have been raising concerns about poor support for and oversight of home birth services for several years.

Separate HSJ research has found  widespread and regular suspensions of the services across the country, underlining their fragility and pushing some women towards giving birth with minimal support.

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Source: HSJ, 20 January 2026