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Inquest into the Death of Baby P

Deceased

Baby P

Demographics

0y, male

Coroner

Coroner Linton

Date of death

2011-07-03

Finding date

2015-06-08

Cause of death

intrapartum hypoxia due to placental abruption

AI-generated summary

A second twin boy was born at home despite medical advice that twin pregnancies require hospital care. The mother, who strongly preferred home birth, disengaged from hospital when her preferences for birth management (vaginal delivery with first twin breech, no continuous monitoring, no epidural) were not fully accommodated. She engaged an unregistered 'birth advocate' and a registered midwife to attend the home birth. During labour, the baby experienced placental abruption and was born lifeless. Prolonged resuscitation in the community delayed optimal care. Medical experts agreed hospital birth with standard management would very likely have prevented death. Key failures: Hospital staff did not adequately impress the serious risks of twin home birth; the unregistered birth advocate provided reassurance rather than clear warnings; the registered midwife's professional obligations to advocate against the unsafe plan were compromised by her backup role; and inadequate documentation of informed consent for the dangerous decision.

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

Specialties

obstetricsmidwiferyneonatologyemergency medicineparamedicine

Error types

communicationdelaysystem

Clinical conditions

twin pregnancyplacental abruptionintrapartum asphyxiabreech presentation (first twin)cephalic presentation (second twin)

Procedures

resuscitationintubationcardiopulmonary resuscitationchest compressionsbag-mask ventilationendotracheal intubation

Contributing factors

home birth of twin pregnancy (high-risk delivery) without adequate medical supervision or resuscitation facilities
placental abruption occurring during delivery
unregistered birth advocate providing midwifery services and false reassurance about safety
lack of continuous foetal monitoring
delayed access to optimal neonatal resuscitation
inadequate communication of risks to parents
premature cessation of hospital engagement by parents
no contemporaneous documentation of informed consent by attendants
inadequate antenatal risk counselling by unregistered and registered attendants

Coroner's recommendations

Passage of legislation similar to South Australia's Restricted Birthing Practices Bill to prevent unqualified and unregistered people from providing planned homebirth services, restricting clinical midwifery services to registered midwives or medical practitioners
Improved communication between health professionals and pregnant women to ensure informed choice comes from understanding of both perspectives within context of mutually respectful relationship
Expansion of continuity of care midwifery models to high-risk pregnancies, not just low-risk pregnancies, to encourage engagement with hospital system
Greater flexibility and negotiation in offering birth environment options to high-risk women within hospital settings to prevent them seeking unregulated alternatives
Development of models of care providing midwifery continuity of care for women of all risk factors to reduce women choosing home birth solely to access continuity of care
Increased availability of facilities such as water immersion for pain management during labour in hospital settings, even for higher-risk pregnancies
Emphasis on non-coercive communication and respect for informed choices while ensuring safety remains paramount
Improved training and emphasis on documentation of informed consent discussions when women choose to decline standard medical recommendations
Protection of home birth model through cautious and conservative decision-making to build community confidence

Full text

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