Queensland baby’s homebirth death ruled ‘preventable’ by coroner
The death of a baby girl three days after a home water birth could have been prevented if she had been born in the hospital, a Queensland coroner had found.
The baby was delivered at her mother’s Gold Coast home on January 10, 2018, by two midwives who admitted to falsifying records after the birth.
The baby was unresponsive, “pale and floppy” at birth, with the umbilical cord wrapped around her neck, coroner Jane Bentley found in a report handed down on Friday.
Midwives commenced CPR before calling paramedics and the girl was placed in the Neonatal Intensive Care Unit at Gold Coast University Hospital.
She was diagnosed with brain damage due to lack of oxygen and died three days later.
“(The baby’s) death was preventable,” the coroner’s report stated.
“It is likely she would have been born a healthy baby had she been born in hospital.”
Three days before the birth, the mother noticed decreased fetal movements and underwent an ultrasound on January 7.
The doctor recommended an immediate induction with hospital birth with continuous fetal monitoring during labour.
The baby’s mother refused and asked to be discharged, stating she “did not want to have the baby in hospital”
“The Registrar … emphasised that RANZCOG (Royal Australian and New Zealand College of Obstetricians and Gynaecologists) does not endorse home births as they are associated with an increased risk to mother and baby,” the coroner found.
The midwife should have refused to assist in a home birth.
The baby was “pale and floppy” when delivered and the coronial inquest also found that midwives had altered their medical notes after the baby’s death.
“The (midwives) dishonesty in colluding to falsify medical records and providing those records and a knowingly false statement for a coronial investigation is astounding,” the coroner found.
The birth record was amended the records to remove all readings which were outside the normal range.
“False readings were inserted to reinforce the false perception that (the bay) was not in distress,” Ms Bentley found.
“The midwife should have refused to assist Ms Ely in a home birth due to the decreased fetal movements on 4 and 7 January 2018 and the recommendation of the doctor at GCUH that she be admitted to hospital and have labour induced.”
The coroner also found paramedics should have been called earlier.
“Had (the mother) stayed in hospital on 7 January 2018 or returned to hospital on the afternoon of 8 January 2018 and had (the baby) in hospital, it is very likely that she would have been a healthy baby.”
The coroner did not refer criminal charges, and recommended Queensland Health consider the development of a standard guideline for planned home births.