Coroner's Court of Western Australia

Inquest into the Death of Baby P

Inquest into the Death of Baby P (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 immediate family, and any identifying information are suppressed.  The deceased is to be referred to as Baby P.

Summary : The deceased was born shortly after his twin on 3 July 2011. The births took place at home. The deceased showed no signs of life at birth.  He was taken by ambulance to the Fremantle Hospital where considerable attempts were made to resuscitate him. Just prior to ceasing resuscitation efforts, a slow, faint heart rate was detected. However, doctors concluded at that time that the outcome for the deceased would be very poor and a decision was made to cease resuscitation, despite the sign of a heart rate.

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

The issues which were explored at the inquest hearing included the jurisdictional question whether or not the deceased was born alive or was still-born. The Coroner concluded that the Court had jurisdiction to continue to make findings and comments in relation to the deceased’s death pursuant to s.25(1) of the Coroners Act 1996.

The inquest also focused on the reasons why the deceased’s parents were led to believe that it was safe to have a home birth when medical advice said it was not. The Coroner found that the evidence at the inquest supports the finding that the decision was made on the background of a strong preference on the deceased’s parents part for a home birth and a perception that the hospital would not accommodate their birth preferences.

The Coroner observed that in making decisions about the place of birth, future parents should give significant weight to the medical opinion as to the risks of avoidable disability or death of their baby and emphasised the importance of extensive and open communication between all parties.

The Coroner found that the deceased died on 3 July 2011 as a result of intrapartum hypoxia due to placental abruption and death arose by way of natural causes.

Catch Words : Home Births : Section 25(1) Coroners Act 1996 : Natural Births : Natural Causes.


Last updated: 26-Apr-2024

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