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Remove items from your saved list<\/a> to add more.<\/p>\n AAA<\/p>\n A baby died after a disastrous home birth attended by two private midwives who provided \u201cdeficient\u201d care and the boy likely would have survived if the labour had taken place in hospital, a coroner has found.<\/p>\n The newborn, referred to in court as Baby R, died from perinatal hypoxia in August 2022 after being delivered during an emergency caesarean at Bendigo Hospital.<\/p>\n On Friday, coroner Dimitra Dubrow found the mother\u2019s pregnancy was not suitable for home birth due to the complications she had experienced with another baby and that the woman\u2019s midwives waited too long to transfer her to hospital when life-threatening complications arose.<\/p>\n \u201cHad Baby R\u2019s mother\u2019s labour occurred in a hospital, such as Bendigo Health … I consider baby R\u2019s death would have been avoided,\u201d she said.<\/p>\n Dubrow said had the labour occurred in hospital, with access to specialist care equipment, signs of \u201cdistress and decompensation\u201d could have been detected and acted upon.<\/p>\n Related Article Last year, the Coroner\u2019s Court heard the 35-year-old mother, who cannot be named for legal reasons, had a complicated and traumatic first birth \u2013 including an emergency C-section and haemorrhaging \u2013 and had decided to have her second child at home.<\/p>\n The inquest was told Bendigo Health rang the woman a month before her due date asking her to come in for an appointment because she was deemed to be at high risk.<\/p>\n But the woman, a former midwife, said she thought it was \u201cfearmongering\u201d and a box ticking exercise for the hospital, so declined the 36-week appointment with an obstetrician.<\/p>\n While the woman\u2019s medical file indicated that an obstetrician had considered her upcoming birth as being at high risk for complications, the mother claimed she was never told her pregnancy was high risk.<\/p>\n Dubrow found the mother was not sufficiently and adequately advised during her pregnancy by any medical staff who treated her, which would have enabled her to make a fully informed decision about the birth.<\/p>\n However, she said the mother\u2019s previous work history suggested the woman might have been \u201ccocooning herself\u201d from the advice of an obstetrician.<\/p>\n \u201cShe likely had an awareness that home birth was outside recommended care,\u201d Dubrow said.<\/p>\n The court heard the woman hired private midwife Elizabeth Murphy in mid-2022, who failed to recommend the mother have a consultation with a specialist obstetrician before the home birth.<\/p>\n When labour began about 5am on August 19, 2022, Murphy and fellow midwife Marie-Louise Lapeyre attended the woman\u2019s Bendigo home.<\/p>\n In a statement read to court last year, the mother said she had a \u201cwhat if\u201d moment during the home birth, when she noticed a gush of meconium liquor, a waste usually passed by a baby post-birth, about 3pm.<\/p>\n The mother recalled saying, \u201cOh f—\u201d, and assumed she would be on her way to hospital.<\/p>\n \u201cI remember [the midwife] Marie-Louise just saying, \u2018We\u2019ll monitor you more closely,\u2019\u201d the mother said.<\/p>\n \u201cI wish I asked what \u2018more monitoring\u2019 looked like to discern if we were on the same page. I didn\u2019t do this, and this is hard to live with.\u201d<\/p>\n Dubrow said the presence of meconium should have been a trigger for both midwives to urgently recommend transporting the mother to hospital.<\/p>\n At 7.45pm, Murphy recommended an urgent transfer to hospital, before the mother made her own way to hospital at 8.25pm.<\/p>\n Lapeyre told the inquest \u201cextreme tiredness\u201d had impaired her judgment, and she deeply regretted delaying the mother\u2019s transfer to hospital.<\/p>\n \u201cThe deep regret was not asking Baby R\u2019s mother what she wanted to do at different points of the labour,\u201d Lapeyre told the court as she broke down in tears. \u201cMidwifery has been the love of my life and I failed … it is devastating.\u201d <\/p>\n Murphy echoed her colleague\u2019s regrets, saying she should have consulted another midwife or obstetrician at the first sign the baby might have been at risk.<\/p>\n \u201cI recognise that in this situation we made mistakes, and I\u2019m so remorseful about that,\u201d she said.<\/p>\n Dubrow was scathing in her findings about the midwifery care provided, which she said was not in accordance with Australian College of Midwives guidelines.<\/p>\n \u201cI consider that the intrapartum care provided by Ms Murphy and Ms Lapeyre was deficient and did not accord with reasonable midwifery care.\u201d<\/p>\n After the finding, Baby R\u2019s family said via a statement through their lawyers at Slater and Gordon the inquest had involved revisiting the \u201cmost painful and traumatic\u201d experience.<\/p>\n \u201cAt the start of the Coronial process, we were told it was happening for one simple reason: our baby\u2019s life mattered,\u201d their statement read.<\/p>\n Related Article \u201cThat truth has been an anchor for our family as we\u2019ve waded through the guilt, fear, anger, silence, shame and pain we\u2019ve carried for the past three and a half years. A loss we will carry for the rest of our lives.\u201d<\/p>\n Dubrow made several recommendations, including the need to better streamline maternity care and guidelines across the Australian College of Midwives, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and Safer Care Victoria.<\/p>\n \u201cIt is desirable that guidance is clear, easy to follow, consistent, and contained in as few guidance documents as possible to minimise the need for familiarity with multiple potentially applicable guidelines and procedures,\u201d she said.<\/p>\n Dubrow said more needed to be done to address birth trauma in the state\u2019s hospital system to ensure ongoing care was trauma-informed.<\/p>\n She recommended that the Australian College of Midwives provide better training to help midwives clearly understand when they should call in a specialist doctor for high-risk pregnancies and called for stricter standards for tracking and charting their fatigue to ensure patient safety.<\/p>\n Start the day with a summary of the day\u2019s most important and interesting stories, analysis and insights. Sign up for our Morning Edition newsletter<\/a>.<\/p>\n Save<\/p>\n You have reached your maximum number of saved items.<\/p>\n Remove items from your saved list<\/a> to add more.<\/p>\n![\"Baby](\"https:\/\/www.newsbeep.com\/au\/wp-content\/uploads\/2026\/05\/fbe9958bbde039a4cdf0a64d0f64129871dd78b6.jpeg\")
Baby R, as the infant was referred to during the coronial inquest last year, died from perinatal hypoxia in August 2022, after he was delivered during an emergency caesarean at Bendigo Hospital.Michele Mossop<\/p>\n![\"Shaken](\"https:\/\/www.newsbeep.com\/au\/wp-content\/uploads\/2026\/05\/1780057636_649_fbe9958bbde039a4cdf0a64d0f64129871dd78b6.jpeg\")
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Melissa Cunningham<\/a> is a health reporter for The Age. She has previously covered crime and justice.Connect via X<\/a> or email<\/a>.From our partners<\/p>\n","protected":false},"excerpt":{"rendered":"Save You have reached your maximum number of saved items. Remove items from your saved list to add…\n","protected":false},"author":2,"featured_media":702148,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[4],"tags":[64,63,44],"class_list":["post-702147","post","type-post","status-publish","format-standard","has-post-thumbnail","category-australia","tag-au","tag-australia","tag-news"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/posts\/702147","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/comments?post=702147"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/posts\/702147\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/media\/702148"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/media?parent=702147"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/categories?post=702147"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/tags?post=702147"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}