Coroner's Court of Western Australia

Inquest into the Death of Baby C

Inquest into the Death of Baby C (Subject to a Suppression Order)

Delivered on :8 June 2015

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : Yes

The names of the deceased, the deceased’s family, and any identifying information are suppressed.  The deceased is to be referred to as Baby C.

Summary : The deceased was born at home.  Assisting at the birth were two independent registered midwives.  At birth the deceased appeared normally developed and healthy. However, sometime within an hour and a half of his birth the deceased began grunting and struggling to breathe.  One of the midwives began to ventilate him and a decision was made to take him to Fremantle Hospital. Upon arrival at the hospital the deceased was in respiratory arrest. Despite intensive resuscitation efforts the doctors could not revive the deceased and he died less than three hours after birth.

The Coroner conducted an inquest hearing into the circumstances surrounding the death of the deceased as part of a joint inquest into three deaths which involved babies born at home in circumstances that were contrary to recognised standards and guidelines for home births in Australia.

A primary focus of the inquest into the deceased’s death was to clarify the circumstances in which he was born, as only limited information had been provided to the coronial investigators by the midwives who attended the birth and the parents of the deceased.

The Coroner found that the deceased died as a result of Group B Streptococcal infection and meconium aspiration with early bronchopneumonia and death arose by way of natural causes.

The Coroner concluded that it is important for extensive communication between the mother and her caregivers prior to delivery, to ensure that when complications present themselves, there is a detailed plan already in place to deal with that situation, with the aim of ensuring a safe outcome for the woman and the baby.

Catch Words : Home Births : Communication Between Mother and Caregivers : Detail Plan should a situation occur : Natural Causes.


Last updated: 26-Apr-2024

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