A coroner has condemned the care provided by two privately-practising midwives to a birthing mother, following the “preventable” death of a six-day-old baby who died after complications from a Victorian homebirth.

The findings into the death of the child – known only as “Baby R” – were handed down by Coroner Dimitra Dubrow on May 29 at the Coroner’s Court of Victoria.

Baby R was born at Bendigo Health on August 19, 2022 by emergency caesarean section after his mother was transferred from a planned homebirth with two privately-practising midwives in attendance.

Baby R was born in poor condition and transferred to the Royal Women’s Hospital in Melbourne, where he died from peri-natal hypoxia on August 25, 2022.

In her findings, Ms Dubrow noted the mother of Baby R gave birth to her first child via an emergency caesarean section in 2019.

The mother suffered a post-partum haemorrhage and described the birth experience as “traumatic”, but the child was otherwise born healthy and well.

Ms Dubrow said Baby R’s mother was a qualified midwife and had conducted significant research about homebirths for her next pregnancy, as she did not want to have another hospital birth.

Privately-practising midwife Elizabeth Murphy said she would be suitable for a homebirth in the future, Ms Dubrow said in her findings.

She ruled Baby R’s mother’s pregnancy was “not suitable for an attempted homebirth” considering the relevant procedures and guidelines, as well as expert opinion given to the court during coronial proceedings.

She said she was “pleasantly surprised” when privately practising midwife Elizabeth Murphy said she would be suitable for a homebirth in the future.

“(Dr Andrew Woods) noted there were a number of risk factors or health concerns in Baby R’s mother’s pregnancy including previous caesarean birth, macrosomic baby, post-partum haemorrhage and traumatic birth experience,” Ms Dubrow said.

“Given the identified risk factors and the various guidance documents, Dr Woods considered Baby R’s mother was not a suitable candidate for homebirth.”

Marie-Louise Lapeyre – a second private midwife in attendance at Baby R’s birth – also accepted Baby R’s mother was not suitable for homebirth “with the benefit of hindsight”.

Ms Dubrow said if Ms Murphy had seriously recommended earlier transfer to hospital, Baby R’s mother would likely have agreed and that could have saved Baby R’s life.

“I am satisfied that had transfer occurred at around or soon after 3:30pm, delivery would have occurred at an earlier time and Baby R’s death would likely have been avoided,” she said.

“Also, Ms Murphy said Baby R’s mother trusted her and that if she had seriously recommended transfer to hospital, Baby R’s mother would likely have agreed.”

Ms Lapeyre said in her evidence that “tiredness may have impaired her decision making” while providing care to Baby R’s mother as she and Ms Murphy had not slept after attending another birth overnight.

Ms Dubrow said in her findings the care provided by the midwives was not adequate – noting there were several deficiencies in their care of Baby R’s mother.

“There was also a failure to act on potential indicators of foetal stress and to appropriately monitor foetal wellbeing and the FHR,” she said.

“I consider that the intrapartum care provided by Ms Murphy and Ms Lapeyre was deficient and did not accord with reasonable midwifery care.”

Speaking outside of court on behalf of Baby R’s family, lawyer Isabelle McCombe said the family had suffered “so much loss”.

“For us, this inquest has never simply been a legal proceeding,” she said.

“It has involved revisiting our most painful and traumatic experiences; an incredibly gruelling process for the family.

“We thank the Coroner and her team for taking the time to understand our baby and the life he never had.”

Ms McCombe said the death of Baby R was a loss his family would carry for the rest of their lives.

“That truth has been an anchor for our family as we’ve waded through the guilt, fear, anger, silence, shame and pain we’ve carried for the past three and a half years,” she said.

“It takes a community to get through hard times, and ours has given our family so much over the past three and a half years.”