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 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.