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 macrosomic babies—risk factors for meconium aspiration and difficult delivery. The midwife failed to: conduct adequate risk assessment; obtain informed consent for water birth acknowledging serious risks; provide adequate lighting (used only candles), preventing early detection of meconium in the birthing pool; perform effective neonatal CPR on an inappropriate surface; and promptly contact emergency services. The midwife had no formal neonatal resuscitation training. AHPRA investigation found care significantly below professional standards. The coroner noted preventability was uncertain but identified failures in risk assessment, monitoring, resuscitation technique, and clinical decision-making regarding home birth suitability.