Finding into death of Chloe Kathleen Gent
Deceased
Chloe Kathleen Gent
Demographics
<1y, female
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.
Error types
Clinical conditions
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
- 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
- Provide written instructions explicitly advising women not to enter the birthing pool in the absence of a midwife
- Revise home birth information pack to include clear guidance on when to call for assistance and emergency procedures
- Update home birth website and materials to include information about potential adverse outcomes and neonatal mortality risk
- Review and clarify protocols for assignment and communication of backup midwife details to ensure correct contact information is provided to birthing families
- Ensure consistent policy documentation across all home birth guidelines to avoid contradictions regarding emergency procedures
- Provide additional training to hospital-based staff (such as Midwife Nguyen who fielded initial calls) regarding home birth protocols for birthing pools
Full text
Related cases
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.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —