Inquest recommends changes after homebirth death
AN INQUEST into the death of a newborn baby following a high-risk homebirth on the Northern Rivers in 2015, has recommended GPs be given greater support in advising patients planning homebirths.
The findings of Deputy State Coroner Harriet Grahame, heard in State Coroners Court in Sydney on Wednesday, also recommended the homebirth program in Lismore be supported and resourced.
The inquest recommended the Northern NSW Local Health District consider implementing an information outreach program to local GPs about the services it currently provides in relation to mothers wanting non-hospital births.
The inquest also made damning revelations regarding the overburdened community service system in Lismore.
"The lack of resources available to the Lismore Community Services Centre (which could have intervened to prevent a high-risk homebirth) was of grave concern," the Coroner said.
Information provided to the inquest stated that about the time of the baby's birth the Lismore Community Services Centre was coping with a "higher than usual number of removal actions" and high volume of work.
The report revealed the baby died on February 19, 2015, at Royal Brisbane and Women's Hospital from injuries received during and just after birth.
The medical cause of the baby's death was hypoxic ischaemic encephalopathy (brain damage).
The findings stated the baby was born breech and without medical assistance and it took some time for effective resuscitation to occur.
Coroner Grahame found, while the parents, whose names have been omitted for legal reasons, were informed of the risks of delivering a baby lying in a transverse (sideways) position, "they seemed unable to properly comprehend or take seriously what they had been told".
"It is extremely unfortunate that once the final scan had been done, they were not warned again in the firmest terms, either by the GP practice they had attended or by a worker from (the) community services (centre)," Coroner Grahame said.
"It is now impossible to know if the mother would have changed her mind had that extra warning taken place."
The inquest found when the baby was seen by Lismore paediatrician Dr Chris Ingall at Lismore Base Hospital, after presenting limp and not breathing at Nimbin Hospital, the doctor was immediately aware that the child had a very poor prognosis. While he tried to communicate this, he said he was met with "stiff resistance" from the baby's father, who appeared to be attempting to "heal" the baby.
The parents wanted 72 hours of healing before the ventilator was removed. For this reason, given the limited resources available at Lismore, the baby was transferred to Brisbane.