Overview
- A Victorian coroner concluded the newborn known as Baby R died of perinatal hypoxia after an emergency caesarean and that an earlier hospital transfer or a hospital birth would likely have prevented the death.
- The coroner found the mother was not suitable for a planned home birth because her pregnancy was not low risk and she had a prior caesarean, facts she had not been adequately advised about to allow a fully informed choice.
- Primary midwife Elizabeth Murphy and colleague Marie‑Louise Lapeyre provided intrapartum care the coroner judged deficient, failed to follow Australian College of Midwives guidance and delayed consulting Bendigo Hospital after signs of fetal compromise such as meconium liquor.
- Both midwives acknowledged mistakes and expressed regret, and regulators have already restricted their ability to practise privately following investigations by AHPRA and the Nursing and Midwifery Board.
- Coroner Dimitra Dubrow recommended that professional bodies and safety agencies streamline and clarify maternity guidance, set clearer consultation and referral triggers, improve trauma‑informed care and introduce better monitoring of clinician fatigue, which could change training and oversight across maternity services.