Coroner finds newborn baby’s death after Victorian homebirth was ‘preventable’, care provided was ‘deficient’

A coroner has condemned the care provided to a laboring mother by two privately employed midwives following the “preventable” death of a six-day-old baby who died following complications during a Victorian home birth.

The findings surrounding the death of the child, known only as “Baby R”, were announced by Coroner Dimitra Dubrow in the Victorian Coroner’s Court on May 29.

Baby R was born by emergency caesarean section at Bendigo Health on August 19, 2022, after his mother was transferred from a planned home birth to the care of two privately employed midwives.

Baby R was born in poor condition and was transferred to the Royal Hospital for Women in Melbourne, where she died from perinatal hypoxia on 25 August 2022.

In her findings, Ms. Dubrow noted that Baby R’s mother gave birth to her first child by emergency caesarean section in 2019.

The mother suffered postpartum hemorrhage and described the birth experience as “traumatic,” but otherwise the child was born healthy and well.

Ms Dubrow said Baby R’s mother was a qualified midwife and had done significant research into home birth for her next pregnancy because she did not want to give birth in another hospital.

Ms Dubrow said her findings suggested that private midwife Elizabeth Murphy would be suitable for home births in the future.

Taking into account the relevant procedures and guidelines, as well as the expert opinion given to the court during the judicial proceedings, it decided that Baby R’s mother’s pregnancy was “not suitable for attempted home birth.”

Private midwife Elizabeth Murphy said she was “pleasantly surprised” when she was told she would be available for a home birth in the future.

“(Dr Andrew Woods) noted that Baby R’s mother had a number of risk factors or health concerns in her pregnancy, including a previous caesarean birth, a macrosomic baby, postpartum haemorrhage and a traumatic birth experience,” Ms Dubrow said.

“Given the identified risk factors and various guidance documents, Dr Woods did not consider Baby R’s mother to be an appropriate candidate for home birth.”

Marie-Louise Lapeyre, the second private midwife who attended Baby R’s birth, also admitted “in hindsight” that Baby R’s mother was not suitable for a home birth.

Ms. Dubrow said that if Ms. Murphy had seriously recommended that he be transferred to hospital earlier, Baby R’s mother would likely have agreed, which could have saved Baby R’s life.

“I am satisfied that had the transfer occurred at or shortly after 3.30pm, the birth would have occurred sooner and Baby R’s death would have likely been prevented,” he said.

“Additionally, Ms. Murphy stated that Baby R’s mother trusted her and that if she had seriously recommended transfer to the hospital, Baby R’s mother would likely have agreed to it.”

In her statement, Ms. Lapeyre said “fatigue may have affected her decision-making process” while caring for Baby R’s mother because she and Ms. Murphy did not sleep after attending the birth for another night.

In her findings, Ms. Dubrow stated that the care provided by midwives was not sufficient and that there were some deficiencies in the care provided to Baby R’s mother.

“There was also a failure to act on potential indicators of fetal stress and to appropriately monitor fetal health and FHR,” he said.

“I consider the intrapartum care provided by Ms Murphy and Ms Lapeyre to be inadequate and not consistent with reasonable midwifery care.”

Speaking outside court on behalf of Baby R’s family, lawyer Isabelle McCombe said the family had suffered “so much loss”.

“For us, this investigation was never just a legal action,” he said.

“It involved revisiting our most painful and traumatic experiences – an incredibly trying process for the family.

“We thank the Coroner and his team for taking the time to understand our baby and the life he never lived.”

Ms McCombe said Baby R’s death was a loss his family would carry for the rest of their lives.

“This truth has been an anchor for our family as we work through the guilt, fear, anger, silence, shame and pain we have carried for the last three and a half years,” he said.

“A community has to get through tough times, and ours has given our family so much over the last three and a half years.”