Coroner rules preventable death of Baby R after deficient homebirth care in Victoria
Consensus Summary
A Victorian coroner ruled that the death of Baby R, who died six days after birth from perinatal hypoxia on August 25, 2022, was preventable. The baby was born via emergency caesarean at Bendigo Health on August 19, 2022, after complications during a planned homebirth attended by two private midwives, Elizabeth Murphy and Marie-Louise Lapeyre. Coroner Dimitra Dubrow found the care provided by the midwives was deficient, noting failures to monitor fetal wellbeing and act on signs of distress, such as meconium liquor detected at 3:10pm and a fetal heart rate of 195 bpm at 7:43pm. She concluded that if the mother had been transferred to hospital earlier, Baby R’s death could have been avoided. Both midwives admitted their care was inadequate, and regulatory bodies restricted their ability to practice as private midwives. The mother, a qualified midwife herself, had previously experienced a traumatic emergency caesarean and post-partum haemorrhage, which Dubrow cited as reasons she was not a suitable candidate for homebirth. The coroner recommended reviewing guidelines for homebirth suitability and communication between healthcare providers to prevent similar tragedies.
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Key details reported by multiple sources:
- Baby R died on August 25, 2022, from perinatal hypoxia six days after birth at the Royal Women’s Hospital in Melbourne
- Baby R was born via emergency caesarean section at Bendigo Health on August 19, 2022, after transfer from a planned homebirth with two private midwives
- Coroner Dimitra Dubrow ruled Baby R’s death was preventable and the care provided by midwives Elizabeth Murphy and Marie-Louise Lapeyre was deficient
- Baby R’s mother had a previous emergency caesarean section in 2019, suffered a post-partum haemorrhage, and described the birth as traumatic
- Baby R’s mother was a qualified midwife and had conducted significant research about homebirths for her pregnancy
- Coroner Dubrow found Baby R’s mother was not suitable for homebirth due to risk factors including previous caesarean, macrosomic baby, and post-partum haemorrhage
- Meconium liquor was detected at 3:10pm on August 19, 2022, during labour, which should have prompted discussion about transfer to hospital
- Coroner Dubrow stated that if transfer to hospital had occurred at or around 3:30pm, Baby R’s death would likely have been avoided
- Both midwives, Elizabeth Murphy and Marie-Louise Lapeyre, conceded their care was inadequate and that a transfer to hospital should have happened sooner
- The Australian Health Practitioner Regulation Agency and the Nursing and Midwifery Board restricted both midwives from practicing as private midwives
- Coroner Dubrow recommended the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and the Australian College of Midwifery review guidelines for homebirth suitability
Points of Difference
Details reported by only one source:
- Coroner Dubrow noted she was 'pleasantly surprised' when Elizabeth Murphy said she would be suitable for a homebirth in the future, despite earlier findings.
- Marie-Louise Lapeyre admitted tiredness may have impaired her decision-making as she and Elizabeth Murphy had not slept after attending another birth overnight.
- Dr Andrew Woods, an expert witness, testified that Baby R’s mother was not a suitable candidate for homebirth based on risk factors and guidelines.
- Lawyer Isabelle McCombe stated the family had suffered 'so much loss' and thanked the Coroner for understanding their baby’s life and the trauma they endured.
- Baby R’s mother described a 'what if' moment during the homebirth when she noticed meconium liquor and recalled saying 'oh f***', assuming she would be on her way to hospital.
- The mother stated she wished she had asked the midwife what 'more monitoring' entailed, which she now regrets.
- At 2:45pm, Baby R’s mother said she 'felt stuck like last time', indicating signs of obstructed labour.
- A fetal heart rate of 195 beats per minute was recorded at 7:43pm, prompting a transfer recommendation by Elizabeth Murphy.
- Coroner Dubrow found Elizabeth Murphy did not act in accordance with Australian College of Midwifery guidelines by stating the mother did not require a specialist obstetrician consultation at 36 weeks.
- Coroner Dubrow also found Castlemaine GP Veronica Moule should have communicated better with Elizabeth Murphy about the risks associated with the mother’s pregnancy.
Contradictions
Conflicting information between sources:
- Newscomau states Coroner Dubrow was 'pleasantly surprised' by Elizabeth Murphy’s statement that she would be suitable for a homebirth in the future, while ABC does not mention this reaction.
- Newscomau explicitly states the midwives were told they 'cannot practise as private midwives', while ABC says they were told they 'cannot practise as private midwives, along with other conditions' (implying additional unspecified restrictions).
Source Articles
Baby dies after ‘deficient’ homebirth care
A coroner has condemned the “deficient” care of two privately-practising midwives after a six-day-old baby died following a homebirth in Victoria.
Coroner finds baby's death after home birth was preventable
A Victorian coroner has found a baby's death could have been avoided if his mother had been transferred to hospital hours earlier, after signs of an obstructed labour.