Finding into death of Caroline Emily Lovell

Contributing factors

• failure to obtain complete obstetric history from previous hospital
• failure to identify and adequately manage known risk factors for PPH (prior PPH, uterine fibroid, retained products of conception)
• failure to manage third stage of labour appropriately (physiological rather than active management)
• failure to remove patient from pool after delivery
• failure to monitor vital signs for over one hour postpartum
• failure to perform vaginal examination despite known risk factors
• inadequate lighting preventing observation of blood loss
• misattribution of symptoms to anxiety rather than hypovolemia
• delay in calling emergency services despite patient's explicit requests
• provision of inaccurate information to paramedics regarding blood loss
• vaginal wall laceration (5cm) through full thickness during delivery
• massive concealed bleeding in birthing pool

Coroner's recommendations

1. The Department of Health and Human Services, in conjunction with the Australian Health Practitioner Regulation Agency, examines the adequacy of the regulatory system currently in place and develops a specific regulatory framework for privately contracted midwives working in the setting of a home
2. The Nursing and Midwifery Board of Australia develops specific guidelines to define mandatory clinical competency and clinical experience standards for privately contracted midwives working in the setting of a home
3. The Nursing and Midwifery Board of Australia develops a system for monitoring mandatory clinical competency and clinical experience standards for privately contracted midwives working in the setting of a home
4. The Department of Health and Human Services provides ongoing training for registered midwives specifically engaged in providing home birth services, with mandatory participation
5. The Department of Health and Human Services undertakes a public campaign designed to provide education for women and partners considering home birth to inform safe and reasonable decision-making
6. The Department of Health and Human Services, in conjunction with the Australian Health Practitioner Regulation Agency, examines whether there is a need to create a regulatory offence that would prohibit receipt of financial commission for attending at a place of birth while being an unregistered midwife or medical practitioner
7. The Director of Public Prosecutions examines the evidence and takes appropriate action against Gaye Demanuele