To find this desperately sad? TW: freebirth death

[ExtraHotDoubleShot]

I just feel so sad for her husband and little boy. I also understand why she didn’t want to go into hospital. Feels like women are stuck between a rock and a hard place with childbirth at the moment.

https://www.theguardian.com/australia-news/2026/jun/20/stacey-warnecke-melbourne-influencer-died-freebirth-inquest-ntwnfb

I've read a few articles and the coroners report.
The coroners report basically says if she'd fully understood the risk she wouldn't have had a homebirth.

I think MWs were almost set up to fail.
The MWs didn't know she was high risk of PPH, or had step B or was anaemic.

Yes they should have clocked the kit they had was damaged before they even brought it out the office.

I'm sure they said she refused monitoring. It was her who wanted the dim candle 🕯 lit room.

The first thing the paramedics did was open the curtains so they could see what they were doing.

If you mean Jennifer their was nothing low risk about it.

The rest well its figures from WHO so world wide with a wide range of health care available or not available.

70% of PPH is utrine atony,
Common triggers: An overdistended uterus (from twins, a very large baby, or too much amniotic fluid), prolonged labor, labor induction, or muscle exhaustion caused by too long a labour or too rapid.

16%_20% is trauma tears and thd like

10%-16% retained placenta

3% clotting disorders.

Mine was too fast delivery.

In the 19th century, women giving birth at home generally suffered fewer deaths than women who gave birth in hospitals or institutional lying-in wards.

And the WHO says women in poor countries experience vastly higher rates of PPH.

Anyone present who doesn’t call for immediate medical help (before the point of emergency, ie as soon as you realise a women is in labour) should be imprisoned for manslaughter eg the “birth keeper”.

Women don’t lose capacity - legally it’s really important.

Whether we need other controls of the doula sector is a separate question.

Well they will because that’s what the Coroner concluded. That their care was grossly negligent. It’s literally all out there for you to read.

I’m not denying her decision to have a homebirth was unwise. I had a PPH with my second and wouldn’t even consider it now despite minimal blood loss with my first. It seemed to come out of nowhere and I felt awful and it wasn’t even a big haemorrhage, all I needed was iron tablets.

But the midwives made errors which reached gross negligence, which is a high bar of neglect to reach. They didn’t record the baby’s heartbeat for over an hour before she was eventually delivered, if I remember rightly. They didn’t take a further urine sample despite the first being worrying. They missed glaring red flags to transfer to hospital. And when the baby was born they lost control completely, I think they described themselves as being in a blind panic. That’s not what you need from midwives.

And the husband? Who is now his orphaned son’s only parent.

I absolutely blame the ‘birth keeper’ for a multitude of reasons, but I’m still stunned her husband didn’t take control of the situation and insist on an ambulance being called. I like to think my DH would never agree to a free birth and would strongly dissuade me to start with. I appreciate her ‘bodily autonomy’ but there’s also the issue of a newborn that needs its mother. I can only assume he didn’t realise the level of danger she was in?

From the Coroners report.
The midwives on call had not been involved in Jen’s antenatal care. I found the omissions in her antenatal care meant the midwives were placed in a detrimental position.

What report finds them Grossly Negligent?

When someone books a HB on the NHS, the midwives are aware of the person's risk status throughout their pregnancy. They can plan for their birth. If people never book in because they cant have a homebirth, you're in a much worse situation.

Read the coroners report.
Coroners report

Honestly, I've always had some questions about this case and I am frankly dubious that the husband knows as much as he thinks he does. I think poor documentation might be a problem here, too.

"Due to the complications in her first pregnancy, in her second pregnancy after her first antenatal appointment she was referred to a Consultant Obstetrician"

Firstly, if you are referred for a OB appintment for review, it is because you have a risk factor. Low risk women do not see OBs. But high risk is a spectrum. You'd know why you were referred because that would be the topic of the appointment, as we see here:

I heard evidence that the advice provided to Jen by the Consultant Obstetrician was for active management of the third stage of labour and intravenous antibiotics in hospital.

So the midwives, Jen and the OBs had a conversation and the plan was made for active management and IVABX which would nearly always have to occur in hospital. HB wasn't mentioned.

In February 2024 Jen told her community midwife she was considering a home birth. Even though her pregnancy was recorded as low risk on the computer system, given her past history she was referred for a further obstetric appointment to discuss her consideration of a home birth. Jen was seen on the 5th March 2024 by an ST4 Trainee in Obstetrics.

When she did want a HB, she was referred back to the OB to discuss because of her history. Again, the topic at this appointment would have been her history and how to manage this at home. That would just be an oxytocin injection vs an oxytocin infusion in hospital plus no IVABX for the GBS+. Remember, nobody can tell her no, they can only tell her that there are increased risks and suggest how to manage them if they are acceptable to her.

I find it difficult to understand what was said at these appointments if it wasnt about risk given they were prompted by an acknowledgement of said risk. If nothing about risk was said, has this doctor been struck off?

You had a home birth but seem to be defending free birth? They are different things.

I’m glad you had successful home births. But if somebody asks you about it, are you able to give a balanced view about risks and benefits? You seem extremely positive about home births and I would worry that you might advise some women poorly due to your clear rose-tinted bias.

I say I am dubious about what the husband knows because when I trained as a doula, we were told that some women do not tell their male co-parents everything because they don't want to have to fight them, too.

In a hospital a grossly negligent midwife would be picked up by machines and other HCPs.

At home, a grossly negligent midwife is god

That isn't necessarily true. Things happen all the time. I read one today where there was a paper jam and a midwife silenced the alarms. When they came back some time later and printed out the trace, it showed the baby in pathological distress. Baby died.

@Hibex Lucy Letby?

Indeed. A horrifying trying horrifying story that has dominated the headlines and continues to do so and will do for much time yet.

And she was picked up.

Out in the community - would not

@Hibex Exactly how long before she was picked up? A long time. Years in fact. And not before she'd done significant damage/caused the deaths of many babies.
If you knew anything about supported hb's you'd also know that in the latter stages of delivery the main mw is supported my another mw. They work closely together. Easy to pick up on malpractice.

Where does it say one person was negligent?

I've read the report about 4 times and I'm not picking that up

I’ve never advised anyone to have a home birth, and very rarely talk about mine unless someone asks me.

I would never have chosen a free birth with my first two, but having had an accidental one with my second, I would choose one over going to hospital if I was going to have a third baby.

And if home births increased in popularity then you'd likely see the same pattern again - because where do you go to give birth if you're high risk, or if you start at home and things go wrong.