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 during precipitous labour. Critical communication failures included: the mother not being informed in writing or verbally not to enter the pool alone, incorrect midwife contact details provided, lack of clarity about emergency procedures, and delays in midwife arrival. The coroner identified that while the precise aetiology of the asphyxia remains undetermined, multiple systemic issues contributed including inadequate written protocols, inconsistent home birth policy documentation, and insufficient information provision regarding risks and procedures. Western Health subsequently amended policies and improved documentation to address these gaps.