Coronial
WAhome

Inquest into the Death of Baby C

Deceased

Baby C

Demographics

0y, male

Coroner

Coroner Linton

Date of death

2010-02-12

Finding date

2015-06-08

Cause of death

Group B Streptococcal infection and meconium aspiration with early bronchopneumonia

AI-generated summary

A newborn died of Group B Streptococcal (GBS) infection and meconium aspiration bronchopneumonia less than three hours after planned home birth. The infant was born to a woman with prior traumatic hospital birth who had declined GBS screening and hospital booking. Labour was prolonged (40 hours membrane rupture, 24 hours active labour). After delivery of a malodorous placenta indicating infection, midwives observed rather than transferring to hospital. The coroner found the midwives failed to follow Australian College of Midwives guidelines: they did not recommend hospital transfer when PROM exceeded 18 hours, did not strongly advise transfer when risk factors were apparent, and did not escalate to medical consultation. Expert evidence indicated intravenous antibiotics in hospital would almost certainly have prevented death. Key failures: inadequate documentation, lack of formal risk counselling despite complex obstetric history (prior caesarean/VBAC at home), no clear escalation plan despite known GBS risks, and failure to engage obstetric support when complications arose.

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

Specialties

midwiferyobstetricspaediatricsneonatology

Error types

diagnosticdelaycommunicationsystem

Clinical conditions

Group B Streptococcal sepsisneonatal sepsismeconium aspirationbronchopneumoniarespiratory distressprolonged rupture of membranesvaginal birth after caesarean (VBAC)

Contributing factors

  • Prolonged rupture of membranes (40 hours)
  • Unknown GBS status due to declined screening
  • Prolonged labour (24 hours active labour)
  • Failure to administer intravenous antibiotics
  • Failure to transfer to hospital when risk factors present
  • Malodorous placenta indicating infection not acted upon
  • Lack of formal risk management plan
  • Inadequate documentation of discussions and decision-making
  • Lack of consultation with obstetrician despite complex history

Coroner's recommendations

  1. Copy of inquest finding to be provided to AHPRA and Nursing and Midwifery Board of Australia for consideration if Sally Westbury returns to jurisdiction and investigation is recommenced
  2. Emphasis on importance of extensive pre-labour communication between women and caregivers to develop detailed risk management plans
  3. Enhanced support for women with prior traumatic birth experiences to develop trust in hospital care, including early psychological assessment and counselling
  4. Better integration and communication between independent midwives and hospital obstetric teams, particularly in complex cases
  5. Adherence to Australian College of Midwives National Midwifery Guidelines for Consultation and Referral, including consultation with medical practitioners when pregnancy falls outside guidelines
  6. Development of clear pathways for women choosing care outside mainstream guidelines, with documented discussions of risks and management plans
  7. Recognition that complex obstetric cases require discussion with senior clinicians and clear documentation of decision-making rationale
Full text
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