Coronial
VIChome2022-10-04

Finding into death of Baby R

3y · Unknown·Unascertained - natural causes; evidence of aspiration pneumonia, hypoxic-ischae…

…-for-gestational-age (SGA, 10th centile). The mother was appropriately excluded from the hospital-supported home birth program due to increased risks associated with SGA. Despite clear medical advice against unassisted h…

obstetricsmidwiferysystemcommunication
WAhome2015-06-08

Inquest into the Death of Baby P

0y · Male·intrapartum hypoxia due to placental abruption

A second twin boy was born at home despite medical advice that twin pregnancies require hospital care. The mother, who strongly preferred home

obstetricsmidwiferycommunicationdelay
QLDhomePodcast2021-09-17

Ely-Smith, Zamia

3y · Female·Hypoxic-ischaemic encephalopathy due to chorioamnionitis due to Gardnerella Vagi…

…mia Ely-Smith died at 3 days of age from hypoxic-ischaemic encephalopathy due to chorioamnionitis following home birth at term. Clinical lessons include: (1) decreased fetal movements at 39+ weeks gestation and hospital …

midwiferyobstetricsdiagnosticcommunication
VIChome2014-04-08

Finding into death of Thomas Freemantle

2y · Male·Severe hypoxic ischaemic encephalopathy (grade 3)

A term two-day-old baby died of severe hypoxic-ischaemic encephalopathy (grade 3) following a home birth on a farm 25km from hospital. The birth was complicated by shoulder dystocia and profound asphyxia. A…

obstetricsmidwiferycommunicationsystem
VIChome2016-02-29

Finding into death of Chloe Kathleen Gent

0y · Female·Perinatal asphyxia

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…

obstetricsmidwiferycommunicationsystem
WAhome2015-06-08

Inquest into the Death of Baby B

0y · Male·severe hypoxic ischaemic encephalopathy due to apparent perinatal asphyxia

Baby B suffered severe perinatal asphyxia during a planned home birth and died from hypoxic ischaemic encephalopathy. An obstetrician recommended hospital delivery based o…

obstetricsmidwiferycommunicationsystem
NSWhome2012-06-28

Roisin Fraser Finding

0y · Female·Hypoxic episode, probably caused by cord entanglement during delivery

A neonate (Roisin) died within 90 minutes of unattended home birth on 27 March 2009. The mother, Janet Fraser, is an advocate for natural birth and rejected all antenat…

obstetricsmidwiferydiagnosticprocedural
VIChome2025-09-12

Finding into death of Baby H

0y · Female·Unascertained

Baby H was born at home on 21 September 2022 following an unassisted birth (freebirth) without medical oversight. The mother had re…

obstetricsneonatologydiagnosticdelay
QLDhome2015-03-23

R, aged one day - Non-inquest findings

0y · Female·meconium aspiration

A full-term female infant (41 weeks 3 days) died from meconium aspiration during a planned home water birth attended by an experienced midwife. The mother had gestational diabetes and a history of macros…

midwiferyneonatologydiagnosticprocedural
VIChome2024

Finding into death of Baby E

1y · Female·Neonatal pneumonia, meconium aspiration and chorioamnionitis secondary to prolon…

Baby E died at home one day after birth at 40+ weeks gestation following a prolonged labour in a hired plastic birthing pool. T…

obstetricsneonatologydiagnosticsystem
NSWhome2016-09-14

Inquest into the death of NA

0y · Male·Hypoxic ischaemic encephalopathy (brain damage) sustained during and just after …

A newborn died from hypoxic-ischaemic encephalopathy following a home birth without medical assistance. The mother had significant risk factors: hepatitis C, anaemia, and transv…

general practiceobstetricscommunicationsystem
VIChospital2013-05-10

Finding into death of Joseph Thurgood Gates

0y · Male·Global cerebral hypoxic injury and perinatal asphyxia secondary to uterine ruptu…

…ed for continuous CTG monitoring. Private midwife Ms Hallinan failed to clearly articulate risks, supported home birth plans despite clinical concerns, and delayed transfer to hospital when foetal bradycardia developed d…

obstetricsmidwiferydiagnosticcommunication
WAhome

Inquest into the Death of Baby AM

0y · Male·severe hypoxic ischaemic encephalopathy secondary to uterine rupture

Baby AM died from severe hypoxic ischaemic encephalopathy secondary to uterine rupture during a planned home vaginal birth after caesarean (VBAC). The mother, Ms M, was 40 weeks and 5 days pregnant, attended by a pri…

obstetricsmidwiferydiagnosticcommunication
TAShospital2017-02-09

Coroner's Finding: DF

0y · Male·extreme prematurity associated with acute chorioamnionitis

A 23-week gestation infant (DF) was born at home in Tasmania and transferred by ambulance to Royal Hobart Hospital with signs of life (sinus bradycardia at …

emergency medicineneonatology
VIChome2024-11-21

Finding into death of Baby S

7y · Male·Hypoxic ischaemic encephalopathy in the setting of a breech delivery

A neonate born at home in breech presentation without medical assistance suffered hypoxic ischaemic encephalopathy and died at 7 d…

obstetricsemergency medicine
VIChome2022

Finding into death of Baby A

0y · Male·Pneumonia in the setting of malnutrition

Baby A, born at home without medical assistance, died at 19 days old from pneumonia complicated by severe malnutrition and dehyd…

neonatologypaediatricsdelaycommunication
VIChome2016-03-24

Finding into death of Caroline Emily Lovell

36y · Female·Global ischaemic injury following cardiorespiratory arrest in the immediate post…

Caroline Lovell, 36, died from postpartum haemorrhage following home birth of her second child. She had significant risk factors: prior PPH with first child and uterine fibroid…

midwiferyobstetricsdiagnosticcommunicationsyntocin
SAhome2007-07-12

Coroner's Finding: STEPHEN Esther Ruth

Female·hypoxic-ischaemic encephalopathy due to intrapartum hypoxia due to delayed deliv…

A 54-hour-old neonate died of hypoxic-ischaemic encephalopathy following a planned home birth of twins. The second twin experienced a prolonged delay in delivery (over 60 minutes) during which fo…

obstetricsmidwifery
VIChome2016-10-06

Finding into death of Martha Alice Fraser

0y · Female·Intrapartum hypoxia due to breech delivery with head entrapment and associated c…

Martha Alice Fraser was born on 30 May 2011 following an unplanned home birth in a frank breech presentation. Her mother, Ms Wood, went into spontaneous labour at home but did not…

obstetricsneonatologycommunicationdelayadrenaline
QLDhospital2017-06-09

Baby L - Non-inquest findings

0y · Female·Group B Streptococcus meningitis and sepsis

…ur complicated by maternal fever (37.6°C), foetal tachycardia (160-170 bpm), and neonatal fever (39.5°C at birth). Despite these signs suggestive of chorioamnionitis, a paediatrician was not notified at birth. The baby …

obstetricsneonatologycommunicationdiagnostic

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