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 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.