A preventable newborn death following a botched planned homebirth in regional Victoria has prompted a coroner to deliver scathing criticism of two private practicing midwives, whose substandard care directly contributed to the six-day-old infant’s death, according to newly released coronial findings.
Coroner Dimitra Dubrow handed down her conclusions into the death of the infant, identified only as Baby R, at Victoria’s Coroner’s Court on May 29, outlining a series of critical failures that led to the tragedy that unfolded in August 2022.
The case traces back to Baby R’s mother, a qualified midwife herself who sought an out-of-hospital birth after a traumatic 2019 emergency caesarean that left her with an intense aversion to hospital deliveries. After her first birth, she experienced a severe postpartum hemorrhage, though her first child survived in good health. For her second pregnancy, she researched homebirth options extensively and was cleared for a planned home delivery by private midwife Elizabeth Murphy, despite multiple clear red flags that disqualified her from the procedure under national clinical guidelines.
Expert witness Dr. Andrew Woods outlined to the court that the mother carried multiple major risk factors: a previous caesarean birth, a suspected large (macrosomic) baby, a history of postpartum hemorrhage, and a prior traumatic birth experience. All of these factors placed her outside the eligibility criteria for planned homebirth, a conclusion Coroner Dubrow echoed in her final ruling. In hindsight, the second attending midwife, Marie-Louise Lapeyre, also acknowledged that the mother was not an appropriate candidate for homebirth.
When labor progressed, complications emerged early, but the midwives failed to recognize signs of fetal distress, neglected consistent and appropriate monitoring of the baby’s heart rate, and delayed a critical transfer to a hospital. By 3:30 p.m. the same day, transfer was already long overdue, but the recommendation was not made to the mother, who trusted her midwives and would have agreed to transfer immediately if urged, according to Coroner Dubrow’s findings. It was only when Baby R’s condition deteriorated sharply that the mother was finally transferred to Bendigo Health, where clinicians performed an emergency caesarean. Born in critically poor condition due to perinatal hypoxia (oxygen deprivation), the infant was transferred to Melbourne’s Royal Women’s Hospital, where he died six days after birth.
In her findings, Dubrow noted another contributing failure: Lapeyre told investigators that fatigue from an overnight birth she and Murphy had attended left her impaired when making decisions during Baby R’s labor, a risk that was left unmanaged by the pair. Dubrow ruled that the intrapartum care provided by both midwives was “deficient” and fell far short of the reasonable standards of midwifery practice. She confirmed that earlier transfer would have resulted in an earlier delivery and almost certainly prevented Baby R’s death.
Speaking outside court on behalf of the grieving family, lawyer Isabelle McCombe described the profound and ongoing pain the family has carried over the 3 and a half years since Baby R’s death. “This inquest has never simply been a legal proceeding,” McCombe said. “It has involved revisiting our most painful and traumatic experiences; an incredibly gruelling process for the family.” She added that the loss will be a weight the family carries for the rest of their lives, noting that the coroner’s findings have brought a measure of clarity amid the family’s struggle with guilt, anger, grief and pain. “We thank the Coroner and her team for taking the time to understand our baby and the life he never had,” McCombe said.