Coronial
VIChome

Finding into death of Chloe Kathleen Gent

Deceased

Chloe Kathleen Gent

Demographics

0y, female

Coroner

Coroner Phillip Byrne

Date of death

2012-02-05

Finding date

2016-02-29

Cause of death

Perinatal asphyxia

AI-generated summary

A 10-day-old infant died from perinatal asphyxia after being born in a home birthing pool. The mother entered the pool without a midwife present after spontaneous rupture of membranes during precipitous labour. Critical communication failures included: the mother not being informed in writing or verbally not to enter the pool alone, incorrect midwife contact details provided, lack of clarity about emergency procedures, and delays in midwife arrival. The coroner identified that while the precise aetiology of the asphyxia remains undetermined, multiple systemic issues contributed including inadequate written protocols, inconsistent home birth policy documentation, and insufficient information provision regarding risks and procedures. Western Health subsequently amended policies and improved documentation to address these gaps.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

obstetricsmidwiferyneonatologyemergency medicine

Error types

communicationsystemdelay

Clinical conditions

perinatal asphyxiahypoxic-ischaemic insultmeconium aspirationintrauterine distressprecipitous labour

Procedures

neonatal resuscitationintubationwater birth

Contributing factors

  • Mother entered birthing pool without midwife in attendance
  • Mother not advised in writing or verbally not to enter pool without midwife
  • Incorrect contact details provided for midwife in transit
  • Delayed midwife arrival (approximately 55 minutes)
  • Lack of clarity regarding emergency procedures for birth prior to midwife arrival
  • Inconsistent home birth protocols regarding ambulance calling procedures
  • Inadequate information provision regarding home birthing risks and procedures
  • Meconium staining indicating intrauterine distress hours before delivery
  • Failure to escalate concerns from prior precipitous labour with previous child

Coroner's recommendations

  1. Amend home birth protocols to clearly state that the woman (or family member) should telephone Ambulance Victoria if birth is occurring prior to arrival of the midwife, ensuring the family can speak directly to ambulance officers during labour
  2. Provide written instructions explicitly advising women not to enter the birthing pool in the absence of a midwife
  3. Revise home birth information pack to include clear guidance on when to call for assistance and emergency procedures
  4. Update home birth website and materials to include information about potential adverse outcomes and neonatal mortality risk
  5. Review and clarify protocols for assignment and communication of backup midwife details to ensure correct contact information is provided to birthing families
  6. Ensure consistent policy documentation across all home birth guidelines to avoid contradictions regarding emergency procedures
  7. Provide additional training to hospital-based staff (such as Midwife Nguyen who fielded initial calls) regarding home birth protocols for birthing pools
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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