Finding into death of Baby S
Deceased
Baby S1
Demographics
7y, male
Date of death
2023-04-08
Finding date
2024-11-21
Cause of death
Hypoxic ischaemic encephalopathy in the setting of a breech delivery
AI-generated summary
A neonate born at home in breech presentation without medical assistance suffered hypoxic ischaemic encephalopathy and died at 7 days old. The mother had been counselled by hospital obstetricians about risks of home breech delivery and advised to present to hospital if labour commenced. Despite these clear recommendations and a planned hospital appointment with a specialist, she did not seek medical help when contractions began at 11am. An ambulance was not called until 4.52pm, after delivery had substantially progressed. The coroner found the death was preventable—hospital delivery would likely have prevented it. Clinicians appropriately counselled the mother and provided clear safety-net advice; the preventable death resulted from the mother's decision not to access recommended care rather than medical error.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- Breech presentation undiagnosed until 28 weeks gestation
- Home birth without medical assistance
- Delayed presentation to hospital after onset of labour
- Prolonged head entrapment during breech delivery (at least 20 minutes)
- Lack of electronic foetal monitoring
- Lack of immediate access to operative delivery
- Maternal decision not to seek medical assistance despite clear advice
Coroner's recommendations
- Publication of these findings to assist expectant parents in decision-making regarding home birth risks and understanding risks of breech delivery
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Source and disclaimer
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