Tragedy befalls family after homebirth results in newborn’s avoidable death

The inquest into the death of Baby R highlighted issues regarding medical advice given over the course of the pregnancy and medical decision-making provided by attending midwives during the homebirth.

In issue

• Baby R was born by emergency caesarean section following a planned but unsuccessful home delivery guided by two midwives. Baby R was six days old when he died on 25 August 2022 from perinatal hypoxia. The aim of the inquest was to investigate the care and management of Baby R’s mother during her pregnancy and labour, and examine the relevant procedures and guidelines relating to homebirth and whether or not Baby R’s mother was a suitable candidate for homebirth.

The background

The inquest spanned from August to September 2025, before Coroner Dimitra Dubrow, in the Coroners Court of Victoria at Melbourne. The decision was handed down on 29 May 2026.

Baby R’s mother, a former midwife, gave birth to her first child via emergency caesarean section at Bendigo Health despite her wishes for a vaginal delivery. The baby was in a deflexed occipito posterior position and being an obstructed birth, the mother suffered postpartum haemorrhage. She described the birth experience as traumatic and was reluctant to give birth in a hospital setting again. She was later provided with a letter from Bendigo Health confirming that she was suitable for a ‘Vaginal Birth after Caesarean Section (VBAC)’ in a future pregnancy. Following discussions with a private midwife and personal research by the parents of Baby R including reviewing Safer Care Victoria guidance documents, a decision was made to proceed with a homebirth on the basis that in their view, this method was safe, produced better outcomes and would allow for a natural birth.

In the leadup to the birth, a birth plan was discussed amongst the midwives and the doula and arrangements were made to transfer to the hospital if the homebirth became problematic. Importantly, the primary midwife, Ms Murphy, failed to stress to Baby R’s parents the importance of a consultation with an obstetrician and failed to refer Baby R’s mother to one. Instead, she arranged for Baby R’s mother to have a ‘booking-in appointment’ (the first appointment at the maternity unit or hospital) and provided a referral letter that omitted critical details relating to Baby R’s mother’s obstetric history. Ultimately, Baby R’s mother declined to make an obstetric appointment.

Baby R’s mother went into labour the day before the due date. The birth progressed without issues until meconium liquor (a baby’s first stool in the womb, staining the amniotic fluid) was discharged and Baby R’s heartrate spiked above the safe range. The primary attending midwife, Ms Murphy, advised that the baby was in distress and required immediate transfer to hospital. Baby R’s father requested a 15-minute period to consider the proposed transfer, in accordance with the birth plan, but given Ms Murphy’s insistence, Baby R’s parents made their way to the hospital.

At the hospital, the cardiotocography (CTG) revealed that Baby R was tachycardiac and a category 1 emergency caesarean section was performed with findings of thick meconium liquor and a deflexed occipito posterior position. Baby R was born with no spontaneous respiratory effort for the first 40 minutes of life, with shallow and irregular breathing afterwards. Later, Baby R was transferred to the Royal Women’s Hospital in Melbourne via the paediatric infant perinatal emergency retrieval service (PIPER) where he was diagnosed with newborn encephalopathy and seizures with renal and hepatic dysfunction. MRI scans performed in the following days confirmed severe hypoxic ischemic brain injury. Baby R’s prognosis was considered poor and it was predicted that he was unlikely to breathe when extubated and even if he survived, he was likely to have a severe disability. Following discussions with Baby R’s parents, a decision was made to institute palliative care measures. Sadly, Baby R died on 25 August 2022, just six days after being born.

The decision

Expert evidence regarding suitability for homebirth and obstetric risk considered there were a number of risk factors or health concerns in Baby R’s mother’s pregnancy including previous caesarean birth, macrosomic baby, postpartum haemorrhage and traumatic birth experience. However, experts were divided on whether these risks translated to Baby R’s mother being unsuitable for a homebirth. In particular, the experts who concluded that Baby R’s mother was a suitable candidate for homebirth considered her traumatic experience and resulting aversion towards obstetricians and suggested that Baby R’s mother had made an informed choice after considering the benefits and risks of choosing a homebirth.

The Coroner however, concluded that Baby R’s mother’s pregnancy was not suitable for homebirth considering the applicable procedures, guidelines and recommendations. She further noted that a consultation with a specialist obstetrician, as required under the Australian College of Midwives: National Midwifery Guidelines for Consultation and Referral, would have ensured that Baby R’s mother was fully informed of the relevant risks, suitability for homebirth and the recommendations set out in the guidance documents.

Regarding care and communication during labour, the Coroner noted that despite the mother’s avoidance of attending an appointment with an obstetrician, who she believed would try and dissuade her from proceeding with a homebirth, it was Ms Murphy’s responsibility, as the primary care provider, to have a consultation with Baby R’s mother about obstetric risk and the impact for potential outcomes in this pregnancy, in line with relevant guidance documents. The Coroner was particularly critical of Ms Murphy’s decision not to refer or book Baby R’s mother for a consultation with an obstetrician based on her personal opinion that Baby R’s mother would not see any benefit in consulting with an obstetrician and would only have an unpleasant experience being at the hospital. The Coroner remarked, 'I consider this was too narrow a view of the content and purpose of a consultation with an obstetrician and it was not for Ms Murphy to assess the contribution or determine the merits and likely impact of such consultation.'

Further, regarding record-keeping, the Coroner noted that not all discussions, including those between midwives, were documented. The Coroner emphasised:

The Coroner found that the intrapartum care provided by the two attending midwives was deficient and did not accord with reasonable midwifery care. She concluded that had Baby R’s mother’s labour occurred in a hospital setting such as Bendigo Health or had the transfer to hospital occurred earlier in the labour, Baby R's death would have been avoided.

Implications for you

Regardless of the express intentions of patients, it is not up to midwives to decide for themselves whether particular advice or assessment of risk is redundant. Rather, it is the midwife’s duty to explain the purpose and importance of a consultation with a doctor and to recommend attendance. While it is ultimately the patient’s choice to give informed consent, all relevant risks, potential consequences and alternatives must be discussed with the patient first before any decision is made by or on behalf of the patient.

The Coroner made two recommendations:

1. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Safer Care Victoria and Australian College of Midwives review this finding with a view to consider how guidance documents relating to maternity care can be streamlined, be more consistent and cross referenced to assist in providing clear guidance to all practitioners providing maternity care, women and their families and the public.
2. The Australian College of Midwives review this finding and the National Midwifery Guidelines for Consultation and Referral and clarify the definition of a 'relevant medical practitioner or other health care provider' in the context of a Level B indication (where the midwife should consult with a medical practitioner and/or another healthcare provider for planning, input or advice).

This inquest is yet again a timely reminder for practitioners to ensure their records are sufficiently clear so that subsequent practitioners can provide continuity of care, and accurately capture discussions regarding treatment options and plans, and informed consent.

Practitioners should seek immediate advice from their relevant professional indemnity association, in similar circumstances.

Finding into Death Following Inquest