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This leaflet produced by the Nursing and Midwifery Council (NMC) can help you decide what you could do if you think a midwife, nurse or nursing associate may have done something wrong. This leaflet explains how we can help if someone has concerns about the care provided by a midwife, nurse or nursing associate during pregnancy, birth or the postnatal period. It covers: what the NMC does and when concerns should be raised with us what happens when someone contacts the NMC where people can go for other types of support, including employers and other organisations that may be better placed to help.

Matilda Gwen Pomfret-Thomas was born on 29 October 2023 at Queen Alexandra Hospital following a difficult labour at home. Hypoxic ischaemic encephalopathy had developed over a period of hours. Meconium had been observed, decelerations were later observed. On 15 November 2023 an investigation into the death of Matilda Gwen Pomfret-Thomas aged 15 days commenced. The investigation concluded at the end of the inquest on 4 December 2025 and the medical cause of death was hypoxic ischaemic encephalopathy. The birth of the family’s first child had been traumatic and, for the birth of their second child, Matilda, they were focussed on achieving a different birth experience and elected to use a doula to provide them with support at a home birth. The hospital’s preference was for a hospital delivery, there was discussion as to what circumstances would result in the mother being blue lighted to hospital. Signs of fetal distress developed but the mother was not immediately transferred to hospital. A difficult atmosphere had developed, the midwives felt access was being restricted by the doula: the coroner found that she did not actively discourage midwife access but that she was seen as, in effect, a buffer by members of the midwifery team. The doula was following the birth plan. The doula was supporting the parents per the birth plan, and this appears to have been perceived as grounds for hope that a home birth was still possible. Matters of concern Doulas provide continuity of care and give emotional, informational and practical support throughout pregnancy, labour and after the birth of a baby: those words come from Doula UK’s website. Doula UK is the largest representative body for Doulas, but it is not a regulatory body, it does not represent all doulas, indeed many doulas are not members of Doula UK. Doula UK have put in place membership requirements, training offers and much guidance, but the role of a doula is clearly diffuse in practical terms and capable of multiple understandings not just by doulas but their clients and midwives. It appears that doulas have been increasingly used and increasingly offer services – as here – on a paid basis. As MNSI (Maternity & Newborn Safety Investigations – formerly HSIB) put it in their report into this birth, “MNSI acknowledges that there is no regulation of doula care or any guidance on how the two services interact with each other. MNSI considers the dynamics of a situation, where a third party are involved can provide additional challenges for staff, such as making clinical recommendations against personal recommendations or views and providing usual care that could be viewed as interference rather than surveillance.” MNSI have identified 12 cases in which there was evidence that doulas worked outside of the defined boundaries of their role and in which the care or advice provided by the doula was considered to have potentially had an influence on the poor outcome for the family. There was evidence given at the inquest by experienced midwifery professionals highlighting that provision of guidance would be helpful for all involved with a birth at which a doula was present. The issues of doula registration, regulation and training are therefore points of concern the coroner would commend for review.

In 2023, Jennifer Cahill was pregnant with her second child. Her antenatal care was managed by Manchester Foundation Trust (“MFT”) community midwives. In 2021 her first pregnancy had resulted in complications at the time of delivery. She had a Post Partum Haemorrhage for which she received an iron and also a blood transfusion. She was also positive for Group B Streptococcal. On the 26 June 2024 an investigation into the deaths of Jennifer and Agnes Cahill was carried out. The Inquests concluded on the 27 October 2025. The conclusion of the Inquests was: Jennifer Rose Cahill died as a result of complications arising from the delivery of her second child, contributed to by neglect. Agnes Lily Wren Cahill died as a result of complications during birth, such complications contributed to by neglect. The medical causes of death were recorded as:  Jen: 1a) Multiorgan failure with disseminated intravascular coagulation 1b) Cardiac arrest due to post-partum haemorrhage 1c) Perineal tear and atony during term delivery. Agnes: 1a Multi-organ insult following hypoxic ischaemic encephalopathy 1b. Cord compression and meconium aspiration syndrome leading to pulmonary hypertension. Key findings Jen had not made an informed decision to have a home birth and if the out of guidance plan had been completed and all the relevant information provided to her, it is more likely than not she would have given birth in an alternative setting and both Jen and Agnes would have survived. If the fetal heart rate monitoring had been conducted correctly and every 5 minutes, it was more likely than not an abnormal fetal heart rate would have been noted up to an hour before Agnes was born and an urgent transfer to hospital would have occurred. The coroner found emergency services would have been on scene when Agnes was born and effective resuscitation would have been administered which would likely have prolonged her life. Had this call been made it is more likely than not Jen would have survived as the after care delivered to her would have noted a perineal tear and administered syntemetrine immediately. The coroner heard evidence that since the deaths, MFT have completely overhauled the home birth service provision. The new service became operational in April 2025. In the six month period within the MFT area of GM they have received requests from 34 women for out of guidance home deliveries. Five of these could not be supported due to safety issues. Of the 29 out of guidance home births, 15 (50%) required transfer to hospital for varying degrees of obstetric emergency. Matter of concerns 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. 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 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. 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. 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. 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. 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. No bespoke training needs analysis has been conducted focusing on midwives practicing in home birth teams. 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 no national guidance on the model of staffing, training and experience for midwives providing home birth care. See also: NHS England's letter responding the Prevention of Future Deaths report.

This toolkit supports integrated care boards (ICBs), their place-based partners, health and care providers to work with service users and professionals to improve the postnatal care experience and both short and long-term maternal and infant health. It shows ICB leaders what an effective, collaborative approach looks like and recommends evidence-based actions for ICBs and providers to consider taking.

Kenhtè:ke Midwives is a primary healthcare provider providing culturally-appropriate maternal and newborn care to Indigenous families living on the Tyendinaga Mohawk Territory and surrounding areas of southeastern Ontario. Tewahséhtha (Miranda Brant) is a Midwife and Erin Ferrant is Administrative Lead.Recognising that birth is a deeply vulnerable time, Kenhtè:ke Midwives works to protect clients from physical, emotional, and cultural harm by fostering trust, honouring traditions, and supporting individual needs. In this blog for Healthcare Excellence Canada, Tewahséhtha and Erin explain how through strong relationships and open communication, Kenhtè:ke Midwives ensures that every birth is safe, respectful, and centred on the whole person.

This initiative aims to improve the identification and treatment of perinatal mental health conditions (PMHC) for all patients throughout the entire perinatal period. For the purposes of the bundle, PMHC includes: mood, anxiety, and anxiety-related disorders that occur during pregnancy or within one year of delivery, including conditions that may have started prior to conception.

.As healthcare organisations continually strive to improve, there is a growing recognition of the importance of establishing a culture of safety. This handbook was published by Healthcare Improvement Scotland to support NHS board maternity services to: understand the importance of safety culture. undertake a patient safety climate survey. understand what the survey results are telling them. develop an improvement plan to address areas that have been highlighted. It includes: the Maternity Services Patient Safety Survey. template letters for NHS boards to adapt for local use. an example improvement plan template.

On the 20 February 2019 an investigation commenced into the death of Bethan Naomi Harris who was born on the 16 November 2018 at the St George's University Hospitals NHS Foundation Trust. Bethan Naomi Harris died at Shooting Star Hospice on the 26 November 2018. Her mother's pregnancy had been uneventful. After admission to labour ward labour progressed very quickly indeed and Bethan sustained severe brain injury during delivery. Despite best efforts by the neonatal team she succumbed to her injuries. The Investigation concluded at the end of the Inquest on the 19 November 2019. The conclusion of the inquest was that the medical cause of Bethan's death was (1a) hypoxic ischaemic encephalopathy. Coroner's Matters of Concern: The Inquest was held one year after Bethan Naomi Harris's death. During the course of the oral evidence it emerged that several, in my mind important, learning issues had not been addressed. There were issues relating to handover of patients to midwives and at the time of Inquest there had been no further specific training in relation to handover. Indeed it was stated that the process in place at the time of Bethan's delivery still pertained without alteration. This represented a risk to patients. At the time of Inquest a team debrief, which I consider to be a source of learning to reduce the risk of serious incident in future was still outstanding. There was little evidence from the oral evidence given that any effective reflection, reflective discussions or learning had taken place subsequent to Bethan's birth and then death. I consider it important that organisations seek to ensure individual and collective reflection to seek to avoid repetition. The evidence for this, one year on, was lacking. St George's University Hospitals response.

This briefing was commissioned by the Maternal Mental Health Alliance who are dedicated to ensuring all women, babies and their families across the UK have access to compassionate care and high-quality support for their mental health during pregnancy and after birth. One woman in five experiences a mental health problem during pregnancy or after they have given birth. Maternal mental health problems can have a devastating impact on the women affected and their families. NICE guidance states that perinatal mental health problems always require a speedy and effective response, including rapid access to psychological therapies when they are needed. Integrated care systems (ICSs) have a unique opportunity to ensure that all women who need support for their mental health during the perinatal period get the right level of help at the right time, close to home. Key points Maternal mental health problems are common and can be extremely serious. Timely access to effective help can make a big difference to long-term health outcomes for mothers and generations to come Integrated care systems can ensure that comprehensive and evidence-based support is provided to women and birthing people during the perinatal period Maternal mental health care must be developed equitably, adapting to the needs of groups of women with higher risk and poorer access to effective support Universal services – midwifery, general practice, and health visiting – are vital to identify needs and provide timely support Access to NHS Talking Therapies is essential for women with many diagnosable mental health difficulties during the perinatal period Specialist community perinatal mental health services are a priority for the NHS Long Term Plan and can meet the needs of women with more serious and complex conditions Adequate provision of specialist Mother and Baby Inpatient Units prevents women being separated from their babies if they need to be admitted to hospital The voluntary sector, including peer support, plays a vital role and needs to be commissioned and properly funded

The aim of the study was to explore the factors that affect the safety attitude and teamwork climate of Cyprus maternity units and Cypriot midwives. The study found that the safety climate in the maternity settings was negative across all six safety climate domains examined. The higher mean total score on team work and safety climate in the more experienced group of midwives is a predominant finding for the maternity units of Cyprus. It could be suggested that younger midwives need more support and teamwork practice, in a friendly environment, to enhance the safety and teamwork climate through experience and self-confidence.

This report by the Royal College of Midwives (RCM) highlights the impact of midwifery staffing shortages on women. It looks at historical failures to invest appropriately in maternity services and talks about a mounting maternity crisis, drawing attention to Care Quality Commission inspections of maternity services that are identifying concerns around safety directly linked to staffing shortages. According to the report’s findings, if the number of NHS midwives in England had risen at the same pace as the overall health service workforce since the last general election, there would be no midwife shortage; there would be 3,100 more midwives in the NHS, rather than having a shortfall of 2,500 full-time midwives. The RCM published the results of a survey last month which showed that midwives give 100,000 hours of free labour to the NHS per week to ensure safe care for women. It also showed that staffing levels were repeatedly cited as cause for concern around the safety of care, and that midwives and maternity support workers are exhausted and burnt out.