Coroner's Court of Western Australia

Inquest into the Death of Baby AM

Inquest into the Death of Baby AM

Delivered on :10 June 2021

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : Yes

A suppression order has been made prohibiting from publication the deceased’s name and any evidence likely to lead to the deceased’s identification.  The deceased is to be referred to as Baby AM.

Summary : Baby AM was five days old when he died at Princess Margaret Hospital on 14 September 2017 from severe hypoxic ischaemic encephalopathy.  This brain injury occurred during birth complications on 8 September 2017.

The deceased’s mother had planned a VBAC homebirth with the support of a local private midwife.  She was aware it was not medically recommended and there was a small risk of uterine rupture which, I occurred, could be catastrophic for both mother and baby.

On 6 September 2017 the deceased’s mother started to experience irregular contractions at home.  On the morning of 8 September 2017 the deceased’s mother was advised that she was in the early stages of labour, but labour was not yet established.  Later on the same day the deceased’s mother was assessed at home by her midwife, it was apparent something had gone wrong.  An ambulance was called to attend as a priority to the house and transfer her to the Busselton hospital.

At the hospital Baby AM’s mother was immediately taken to the operating theatre and given anaesthetic.  The doctor performed a lower segment caesarean section.  A uterine rupture was found and Baby AM was located partly in the abdominal cavity.  Baby AM was delivered pale and had minimal muscle tone.  He was intubated, ventilated and urgently transferred to Princess Margaret Hospital for specialist treatment.  His mother required urgent surgery to repair her ruptured uterus and she was also hospitalised.

At Princess Margaret Hospital Baby AM underwent an MRI of his head on 12 September 2017 which showed he had suffered a severe brain insult, that had resulted in permanent damage to a very large part of his brain.  It was considered that if Baby AM survived, he was likely to have very significant physical and intellectual disabilities.  After discussion with parents about his poor prognosis, the decision was made to withdraw active treatment.  He was kept comfortable until he died peacefully on 14 September 2017.

The Deputy State Coroner held this inquest to explore what information was provided to the parents about the risks of a VBAC home birth and what relevant information and options are available in the South west region for others who wish to consider attempting a planned VBAC.  The Deputy State Coroner was satisfied from all of the evidence that Baby AM’s parents were well informed, both through their own research and through consultation with medical staff and that they made their choice and were accepting of the risks involved.  The Deputy State Coroner also accepted that the current system whilst not ideal, is appropriate to cater for the demand for VBAC’s and home births in the South West region.

Catch Words : VBAC at home : Information and advice as to the risks : Natural Causes

Last updated: 25-Jun-2021

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