What is a Coronial Inquest? Key Insights for Queensland

A coronial inquest helps uncover the reasons behind unexpected or unexplained deaths. It provides clarity to grieving families and helps prevent similar tragedies in the future. In Queensland, a coronial inquest is a formal investigation led by a coroner. The coroner’s job is to find out how the death happened and recommend ways to improve public health and safety. The goal is not to blame anyone but to learn from what happened.

This article explains what a coronial inquest is, how it works, and why it matters. We’ll also look at the case of Zamia Ely-Smith, a tragic example of medical failure.

How a Coronial Inquest Works

At the end of a coronial investigation, the coroner provides key details about the death. These include:

• Who the person is
• How they died
• When they died
• Where they died
• What caused the death

In Queensland, a coronial inquest can also include suggestions to improve safety and prevent future deaths. These findings are shared with the family, relevant authorities, and posted on the Queensland Court website. Any recommendations are sent to government departments for action.

What a Coronial Inquest Does

A coronial inquest is not a trial. It doesn’t focus on blaming anyone. Instead, it looks at how the death happened and aims to reduce the chances of similar deaths in the future. The coroner must base their findings on the “balance of probabilities,” meaning they must decide which explanation seems most likely based on the evidence.

The Death of Zamia Ely-Smith

Zamia Ely-Smith tragically died on 13 January 2018 at the Gold Coast University Hospital. Her death was caused by hypoxic-ischaemic encephalopathy, a condition linked to lack of oxygen to the brain. This was due to chorioamnionitis, which resulted from an untreated rupture of membranes for over 18 hours. Poor medical management contributed to her death.

Timeline of Events

Zamia’s mother, Ms Ely, was under the care of midwives from “My Own Midwife gc.” She reported reduced fetal movements on 7 January 2018. Despite this, the midwives told her a home birth was still an option if she continued to feel fetal movements.

On 9 January 2018, Ms Ely went into labour after days of reduced movements. Zamia was born on 10 January 2018, but she was unresponsive, pale, and not breathing. Despite efforts to save her, she died on 13 January 2018.

Midwives’ Actions and Findings

The inquest revealed that the midwives had falsified medical records to hide their poor care. One midwife changed the records to show that Zamia was not in distress, even though she was.

Expert Opinion

Dr Rod Allen, who gave expert advice during the inquest, found that Ms Ely’s labour was mismanaged. Key failures included:

• Ignoring clear signs that a home birth was no longer safe.
• Incorrectly monitoring the baby’s condition.
• Failing to transfer Ms Ely to the hospital in time.

Dr Allen noted that proper care could have saved Zamia’s life.

Coroner’s Findings

On 17 September 2021, Deputy State Coroner Bentley concluded that the midwives’ mismanagement played a key role in Zamia’s death. She stated that if the midwives had acted earlier or called for an ambulance, Zamia’s death might have been prevented.

Coroner’s Recommendations to Queensland Health

As a result of the inquest, the coroner made several recommendations to Queensland Health to improve safety during home births. These included:

1. Home Birth Guidelines: Clear guidelines on when home births are safe and when patients should be transferred to a hospital.
2. Required Equipment: A list of necessary equipment for home births, including monitors and resuscitation tools.
3. Neonatal Resuscitation Training: Ensuring midwives are trained in advanced resuscitation techniques.

Queensland Health’s Response

In July 2022, Queensland Health responded to the inquest. They stated that at the time of Zamia’s death, they did not have a publicly funded home birth program. However, since then, they have introduced publicly funded home birth services. 

In February 2024, they released a Guideline for Implementing a Publicly Funded Homebirth Program, which focuses on ensuring safety during home births.

RANZCOG Clinical Guidelines

In July 2023, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) updated their clinical guidelines on home births. These updates were influenced by the lessons learned from Zamia’s inquest. The guidelines provide healthcare professionals with evidence-based advice on home births.

Contact Medical Law Today

The inquest into Zamia Ely-Smith’s death highlights the importance of proper medical care during childbirth, especially during home births. The coroner’s findings and recommendations have led to changes in how home births are managed in Queensland, improving safety for mothers and babies.If you or a loved one has been affected by medical negligence during pregnancy, labour, or childbirth, it’s important to seek legal advice. You may be entitled to compensation, and holding healthcare providers accountable can help prevent future tragedies. Contact us today to discuss your legal options.