Coroner finds death of baby girl after home water birth was preventable
The death of a baby girl three days after a home water birth could have been prevented if she had been born in the hospital, a Queensland coroner has found.
The baby was delivered at her motherās Gold Coast home on January 10, 2018, by two midwives who admitted to falsifying records after the birth.
The baby, Zamia Ely-Smith, was unresponsive, āpale and floppyā at birth, with the umbilical cord wrapped around her neck, coroner Jane Bentley found in a report handed down on Friday.
MidwivesĀ commenced CPR before calling paramedics and the girl was placed in the Neonatal Intensive Care Unit at Gold Coast University Hospital.
She was diagnosed with brain damageĀ due to lack of oxygen and died three days later.
ā(The babyās) death was preventable,ā the coronerās report stated.
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āIt is likely she would have been born a healthy baby had she been born in hospital.ā
Three days before the birth, the mother noticed decreased fetal movements and underwent an ultrasound on January 7.
The doctor recommended an immediate induction withĀ hospital birth with continuous fetal monitoring during labour.
The babyās mother refused andĀ asked to be discharged, stating she ādid not want to have the baby in hospitalā
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āThe Registrar ā¦ emphasised that RANZCOG (Royal Australian and New Zealand College of Obstetricians and Gynaecologists) does not endorse home births as theyĀ are associated with an increased risk to mother and baby,ā the coroner found.
The baby was āpale and floppyā when delivered and theĀ coronial inquest also found that midwives had altered their medical notes after the babyās death.
āThe (midwives) dishonesty in colluding to falsify medical records andĀ providing those records and a knowingly false statement for a coronialĀ investigation is astounding,ā the coroner found.
The birth record was amended the records to remove all readings which wereĀ outside the normal range.
āFalse readings were inserted to reinforce the false perception that (the bay) was not in distress,ā Bentley found.
āThe midwifeĀ should have refused to assist Ms Ely in a home birthĀ due to the decreased fetal movements on 4 and 7 January 2018 andĀ the recommendation of the doctor at GCUH that she be admitted to hospital and have labour induced.ā
The coroner also found paramedics should have been called earlier.
āHad (the mother) stayed in hospital on 7 January 2018 or returned to hospitalĀ on the afternoon of 8 January 2018 and had (the baby) in hospital, it is veryĀ likely that she would have been a healthy baby.ā
The coroner did not refer criminal charges, and recommendedĀ Queensland Health consider the development of a standard guideline forĀ planned home births.
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