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 on the mother's previous unexplained neonatal emergency. However, Community Midwifery Program midwives, through miscommunication and failure to follow up with the obstetrician, allowed the mother to believe a home birth was approved. Critical failures included: the primary midwife not contacting the obstetrician as requested, the manager neither emailing the obstetrician nor ensuring clear policies were followed, and inadequate documentation. No formal confirmation of the obstetrician's decision was communicated to other healthcare staff. The case highlights the necessity for unambiguous written documentation of high-risk pregnancy decisions and mandatory communication protocols between midwifery programs and medical staff to prevent similar deaths.