After reviewing Ms Lovell's tragic death after a home birth in 2012, Coroner Peter White recommended the Director Of Public Prosecutions examine whether charges should be laid against Ms Demanuele for her role in the preventable death. Caroline Lovell died at the Austin Hospital in January 2012. Ms Lovell, 36, died about 12 hours after giving birth at her Watsonia home on January 24, 2012. Coroner White also called for a review of the regulation of midwives caring for women during home births, and for the government and health authorities to consider an offence banning unregistered health practitioners from taking money for attending home births. At the time of Ms Lovell's death, Ms Demanuele was registered, but four months later, she wrote to the Australian Health Practitioner Regulation Agency to say that she was forfeiting her registration because she did not want to work in a system that coerced women into receiving medical treatment during birth. She has since continued to offer her services.

On Thursday, Coroner White said Ms Lovell's death could have been prevented and that various acts and omissions by Ms Demanuele had "caused, or substantially contributed to" her death. Caroline Lovell's mother, Jade Markiewicz, speaks outside the Coroners Court on Thursday. Credit:Penny Stphens While Ms Demanuele should have been more rigorous in her assessment of Ms Lovell's birthing history before agreeing to care for her during a home birth in the first place, Coroner White said she then failed to actively monitor Ms Lovell's vital signs after she had given birth to her daughter. Coroner White said he accepted medical evidence that Ms Lovell had, in effect, "bled out" in a birthing pool where she remained for an hour in a dark room after delivering her baby. Unregistered midwife Gaye Demanuele.

During this time, he said Ms Demanuele did not examine Ms Lovell, monitor her blood loss effectively, or check her blood pressure. When Ms Lovell tried to get out of the pool, she fell unconscious. She suffered a cardiac arrest and was taken to the Austin hospital but died about 12 hours later. Coroner White said Ms Lovell had a history of complications following her first birth and had had several other gynaecological treatments that should have been red flags to Ms Demanuele when considering whether Ms Lovell should have a home birth.

He said Ms Demanuele could have insisted on getting Ms Lovell's medical records from Geelong Hospital where she had previously given birth, but instead she chose to rely on Ms Lovell's recollections alone. After Ms Lovell gave birth at home in 2012, Coroner White said the baby had blood on her head - a sign that Ms Lovell may be bleeding. Despite this, Ms Demanuele allowed Ms Lovell to remain in the pool for an hour unchecked. Her baby was with her most of the time so they could bond. Had Ms Demanuele turned on the lights, Coroner White said she may have noticed the pool had turned a reddish brown due to her blood loss. The blood loss was likely caused by injuries to her vaginal wall, perineum, and probably her uterus. When Ms Lovell tried to get out of the pool, she fainted. After regaining consciousness, Ms Lovell said she feared she was dying and asked for an ambulance to be called. Ms Demanuele did not call an ambulance. Later, Ms Lovell collapsed again. Ms Demanuele started CPR and an ambulance was called. However, by the time paramedics arrived, she was in cardiac arrest. Ms Lovell was taken to the Austin Hospital, but she suffered serious brain damage and died.

Coroner White said Ms Demanuele had attributed Ms Lovell's breathlessness, agitation and fear to anxiety "in a setting in which Gaye steadfastly maintained her commitment to home birth, without outside intervention". "In other words, I find that these acts and omissions were undertaken without objective judgement, and with little regard for the norms and protocols adhered to by her peers," he said. Coroner White said while Ms Lovell was being treated at the Austin, Ms Demanuele returned to her Watsonia home and removed the pool and its contents, "despite what I am satisfied was her comprehension of the potential relevance of this evidence to questions likely to be later asked of her". Ms Demanuele was accompanied by a less experienced midwife Melody Bourne, but Coroner White said Ms Demanuele was controlling Ms Lovell's care. He said Ms Demanuele had:

failed to conduct a proper risk analysis before deciding to approve a home birth for Ms Lovell

failed to consult Ms Lovell's GP throughout her antenatal care

failed to provide a safe environment for her to give birth, which made it difficult to observe the complications unfolding

failed to call for an ambulance when Ms Lovell needed one; and

failed to provide paramedics and Austin hospital staff with adequate information. Having heard that Ms Demanuele had been involved in other questionable care, including oversight over a home birth where the baby was stillborn, Coroner White said the regulatory system may have also failed Ms Lovell. He recommended the department of health and the Australian Health Practitioner Regulation Agency review the case and develop a specific regulatory framework for private midwives who do home births. He said the Nursing and Midwifery Board of Australia should also be doing more to monitor the competency of home birth midwives. Coroner White also called for a public campaign to educate women and their partners about the safety of home birth. He said women should have choice over where and how they give birth, as long as they are properly educated about the risks. Outside court, Ms Lovell's friend Rita Linnestad and her mother, Jade Markiewicz, said Ms Lovell was a wonderful person who they missed terribly. Ms Markiewicz said Ms Demanuele was a danger to women and that her only child should not have died.

"Caroline was a beautiful person and loving mother who thought that she was in safe hands giving birth at home. She never thought that when she begged to be taken to hospital that her cry for help would be rejected," she said. Ms Markiewicz's lawyer Michael Magazanik said she was now planning to sue over her daughter's death and that the role of the Australian Health Practitioner Regulation Agency was open to question. "We are aware of another home birth in mid 2011 when a woman begged Ms Demanuele to call an ambulance. Demanuele refused. The baby died," he said. Loading "Five months later Demanuele attended Caroline's birth and again refused to call an ambulance when her patient begged for one. This raises questions about the regulator's management of the registration of midwives and its failure to act after the first incident."