Coroner's Finding: Home Birthing - SPENCER-KOCH Tate and HOBBS Jahli Jean and KAVANAGH Tully Oliver
Deceased
Tate Spencer-Koch, Jahli Jean Hobbs, Tully Oliver Kavanagh
Demographics
unknown
Date of death
2007-07-16
Finding date
2012-06-06
Cause of death
Tate Spencer-Koch: intrapartum hypoxia due to shoulder dystocia; Jahli Hobbs: intrapartum hypoxia due to placental abruption; Tully Kavanagh: hypoxic-ischaemic encephalopathy due to placental abruption
AI-generated summary
Three neonates died following complications during planned homebirths attended by midwife Lisa Barrett. Tate Spencer-Koch (4790g, macrosomic) died from intrapartum hypoxia caused by shoulder dystocia; delivery was obstructed for 20 minutes with inadequate assistance. Jahli Hobbs (breech presentation) died from placental abruption during a breech delivery without continuous monitoring; CTG would likely have enabled timely intervention. Tully Kavanagh (second twin) died from hypoxic-ischaemic encephalopathy caused by placental abruption; he was delivered after an 80-minute delay, en route to hospital. All three deaths were associated with high-risk pregnancies unsuitable for homebirth: macrosomia with shoulder dystocia risk, breech presentation, and twin pregnancy. Hospital births with continuous monitoring, immediate access to intervention, and availability of skilled assistance would probably have prevented these deaths. The coroner found Barrett's practice reflected inadequate appreciation of risk and non-compliance with clinical guidelines for consultation and referral.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- planned homebirth in high-risk pregnancies
- macrosomia with increased shoulder dystocia risk
- breech presentation
- twin pregnancy with prolonged delivery interval
- inadequate foetal monitoring
- lack of continuous cardiotocography
- absence of immediate advanced resuscitation resources
- lack of skilled assistance for emergency manoeuvres
- absence of timely transfer to hospital
- inadequate informed consent regarding risks
- midwife's non-compliance with consultation and referral guidelines
- inadequate communication of established risk factors to parents
Coroner's recommendations
- Bring into operation section 10 of the Health and Community Services Complaints (Miscellaneous) Amendment Act 2011 to insert Part 6 Division 5, and introduce legislation rendering it an offence for any person to engage in midwifery practice, including management of the three stages of labour, without being registered as a midwife or medical practitioner under the National Law
- Introduce legislation imposing a duty on any health service provider to report to South Australian Department of Health and Ageing the intention of any person to undergo a homebirth attended by enhanced risk of complication (e.g. twin birth, known breech presentation at term)
- Upon notification of intention to undergo high-risk homebirth, Chief Executive Officer of SA Department of Health and Ageing shall cause advice to be tendered by a senior consultant obstetrician regarding desirability of homebirth in the particular case
- Consider establishment of a position of Supervisor of Midwives based on the United Kingdom model
- Consider establishment of alternative birthing centres as contemplated by the Australian Medical Association (South Australian Branch)
- Provide public education regarding risks associated with certain types of birth including twin births and breech births; how these risks are affected by homebirth choice; that adverse outcomes in homebirth would not inevitably have occurred in hospital; that second born of twins would not inevitably be immediately intervened upon; the need and mandatory nature (or otherwise) of epidural pain relief in hospital birthing
- Bring into operation the revised Policy for Planned Birth at Home in South Australia with specific identification of current risk factors for shoulder dystocia
- In any case where clinicians in a public hospital become aware that a patient intends to undergo high-risk homebirth, appropriate advice shall be tendered by a senior consultant obstetrician
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