A damning report into the death of a baby has revealed more babies could die as a result of labour complications if action is not taken.
The coroner's report, which examined the death of four-day-old Sussex baby Arthur Trott revealed there is a risk future deaths could occur if action is not taken.
Baby Arthur died following an unexpected breech delivery, meaning he was lying feet first rather than head first.
Initial advice from the labour ward and consultant midwife was to bring the mother into hospital.
But on arrival at the mother's home a decision was made to attempt deliver there.
The inquest into baby Arthur's death found that the delay in getting him to Royal Sussex County Hospital made a "material contribution" to his death.
Baby Arthur arrived at RSCH on May 24 last year in a "very poor condition".
Four days later, he died there from hypoxic ischaemic encephalopathy, a severe brain injury that occurs when a baby's brain does not receive enough oxygen during delivery.
The report concludes that home deliveries should not be attempted when the baby is not able to be delivered head-first.
The coroner also found that there are only two consultant midwives employed by ambulance services despite there being 11 ambulance organisations in England.
Karen Henderson, assistant coroner for West Sussex, said: "This leaves the majority of ambulances services having no obstetric support, guidance or ongoing teaching and training.
"As a matter of urgency there is a need to provide resources to employ more consultant midwives - at least one to two per service - throughout all the ambulance organisations."
The report was sent to the Joint Royal Colleges Ambulance Liaison Committee (JRCALC).
Ms Henderson concluded that action should be taken to prevent future deaths and said she believed the organisation has the power to take such action.
The JRCALC must respond to the report within 56 days of the date it was published, by January 24, 2023.
Their response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, it must explain why no action is proposed.
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