May 29, 2026 — 3:13pmA baby died after a disastrous home birth attended by two private midwives who provided “deficient” care and the boy likely would have survived if the labour had taken place in hospital, a coroner has found.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.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 MossopOn Friday, coroner Dimitra Dubrow found the mother’s pregnancy was not suitable for home birth due to the complications she had experienced with another baby and that the woman’s midwives waited too long to transfer her to hospital when things went wrong.“Had Baby R’s mother’s labour occurred in a hospital, such as Bendigo Health ... I consider baby R’s death would have been avoided,” she said.Dubrow said had the labour occurred in hospital, with access to specialist care equipment, signs of “distress and decompensation” could have been detected and acted upon.Last year, the Coroner’s Court heard the 35-year-old mother, who cannot be named for legal reasons, had a complicated and traumatic first birth – including an emergency C-section and haemorrhaging – and had decided to have her second child at home.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.But the woman, a former midwife, said she thought it was “fearmongering” and a box ticking exercise for the hospital, so declined the 36-week appointment with an obstetrician.While the woman’s 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.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.However, she said the mother’s previous work history suggested the woman might have been “cocooning herself” from the advice of an obstetrician.“She likely had an awareness that home birth was outside recommended care,” Dubrow said.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.When labour began about 5am on August 19, 2022, Murphy and fellow midwife Marie-Louise Lapeyre attended the woman’s Bendigo home.In a statement read to court last year, the mother said she had a “what if” moment during the home birth, when she noticed a gush of meconium liquor, a waste usually passed by a baby post-birth, about 3pm.The mother recalled saying, “Oh f---”, and assumed she would be on her way to hospital.“I remember [the midwife] Marie-Louise just saying, ‘We’ll monitor you more closely,’” the mother said.“I wish I asked what ‘more monitoring’ looked like to discern if we were on the same page. I didn’t do this, and this is hard to live with.”Dubrow said the presence of meconium should have been a trigger for both midwives to urgently recommend transporting the mother to hospital.At 7.45pm, Murphy recommended an urgent transfer to hospital, before the mother made her own way to hospital at 8.25pm.Lapeyre told the inquest “extreme tiredness” had impaired her judgment, and she deeply regretted delaying the mother’s transfer to hospital.“The deep regret was not asking Baby R’s mother what she wanted to do at different points of the labour,” Lapeyre told the court as she broke down in tears. “Midwifery has been the love of my life and I failed ... it is devastating.” Murphy echoed her colleague’s regrets, saying she should have consulted another midwife or obstetrician at the first sign the baby might have been in distress.“I recognise that in this situation we made mistakes, and I’m so remorseful about that,” she said.Dubrow was scathing in her findings about the midwifery care provided by Murphy, which she said was not in accordance with Australian College of Midwives guidelines.“I consider that the intrapartum care provided by Ms Murphy and Ms Lapeyre was deficient and did not accord with reasonable midwifery care.”After the finding, Baby R’s family said via a statement through their lawyers at Slater and Gordon the inquest had involved revisiting the “most painful and traumatic” experience.“At the start of the Coronial process, we were told it was happening for one simple reason: our baby’s life mattered,” their statement read.“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. A loss we will carry for the rest of our lives.”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.“It 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,” she said.Dubrow said more needed to be done to address birth trauma in the state’s hospital system to ensure ongoing care was trauma-informed.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.Start the day with a summary of the day’s most important and interesting stories, analysis and insights. 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