Homebirth midwife Lisa Barrett found not guilty, but hardly exonerated.

not guilty grunge stamp

Deregistered Australian midwife Lisa Barrett was found not guilty in two homebirth deaths.

A former South Australian midwife charged over the deaths of two babies during home births has been found not guilty of two counts of manslaughter.

In the first case of its kind in Australia, Lisa Barrett, 52, pleaded not guilty over the deaths of Tully Kavanagh in 2011 and another baby boy in 2012, who cannot be identified.

In the Supreme Court on Tuesday Justice Ann Vanstone cleared her on both counts…

“Although I find that the accused’s conduct was less than competent, I am not satisfied that her conduct merits criminal sanction.

“My verdict in relation to each count is not guilty.”

I have written about Barrett repeatedly over the past decade. Her involvement in multiple homebirth deaths nearly defies belief.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Who’s responsible when a baby dies at homebirth, mother or midwife?[/pullquote]

Tate Spencer-Koch, Jahli Jean Hobbs, Sam, Tully Kavanaugh and Ian died because Lisa Barrett minimized the risks of homebirth when counseling their mothers, all of whom were at high risk for complications. Of these deaths, 1 was a shoulder dystocia, 2 were second twins, and 2 were breech babies. They died because Lisa Barrett could not handle the complications that were predicted. They died because their mothers did not have the Cesareans that would have saved the babies lives.

The practice of homebirth is notable for its recklessness, but even so Lisa Barrett was in a class by herself. During the Coroner’s inquest into the deaths of Tate and Jahli Jean, Barrett was caught live tweeting the proceedings and offering scathing comments about the prosecution’s case. If that weren’t contemptuous enough, Barrett also managed to find the time to attend Tully’s homebirth death. As a result, the Coroner’s inquest was expanded to include both Tully’s death and Sam’s death.

The report, released in 2012 was scathing in its assessment of Barrett’s conduct. So why wasn’t she found guilty of criminal charges?

I don’t yet have access to the full decision, but I suspect it might have something to do with the argument made by her defense counsel:

In closing submissions, Scott Henchliffe, for Barrett, said there “was no law that made anything that Barrett did, that we have heard about in this case, illegal”.

He said the two mother’s whose babies died had “self-serving memories” of their pregnancies and births and held Barrett responsible for the outcomes.

“The decision to homebirth was their own and in the most general sense it was that decision which, when the risks eventuated, led to both them losing their babies,” he said.

“It’s only human nature for them to seek to put themselves in the light where they carry less guilt or blame or responsibility for what ultimately occurred.”

In other words, these mothers knew the risks, took the gamble and lost.

There’s considerable evidence to support that defense in the case of Tully Kavanaugh. During the inquest into his death:

Expectant mother Sarah Kerr told an obstetrician she was willing to risk the death of one of her twins by having a home birth, a court has heard…

Dr Raman told Deputy State Coroner Anthony Schapel that Ms Kerr, seemed to have “made up her mind” about having a home delivery. That was despite knowing the increased risk of giving birth to twins at home.

“She said she understood either twin could die and she wanted to accept that risk,” Dr Raman said.

And if that weren’t damning enough:

Dr Raman said she asked Ms Kerr about her ante-natal care and who her treating midwife and general practitioner was.

She said Ms Kerr replied that birthing advocate and former midwife Lisa Barrett had been advising her with her pregnancy, but that she didn’t support the couple’s decision to have a home birth.

“She said her midwife didn’t support her twin delivery at home and she wasn’t in favour of it,” Dr Raman said.

Furthermore, Kerr testified at the inquest in defense of Lisa Barrett. Noting that she had attended an earlier hearing about Barrett’s involvement in other homebirth deaths:

In the Coroner’s Court yesterday, Ms Kerr said she was not discouraged from a home delivery despite in August hearing of the adverse outcomes of home births. Ms Kerr told Deputy State Coroner Anthony Schapel she took full responsibility for her actions and was aware of the increased risk of the delivery of twins.

“No one can say I didn’t make an informed choice, I sat through every day of evidence,” she said.

It was only later that Kerr decided she had been misled.

So Lisa Barrett was hardly exonerated and she has paid a high price — legally and financially — for her recklessness. But, at least in Australia, it appears that mothers who choose homebirth in defiance of medical advice bear greater responsibility for the outcome than the midwife who agreed to help them.

  • mysteriousgeek

    I have to agree. In all the self education these mothers do on the web, surely they must come across the news that babies die at homebirths. They just choose not to read those stories. It’s extremely difficult for me to believe they don’t know there are risks. It’s just like my friends who still smoke and say “Well everything causes cancer” – yes, but you don’t go huffing asbestos.

  • MaineJen

    Jesus wept.

  • EmbraceYourInnerCrone

    OT but another tragic lack of medical care for a child: https://www.cbc.ca/news/canada/calgary/clark-sentencing-jennifer-jeromie-toddler-1.5163071

    “The trial jury was also shown screenshots of online searches for natural remedies for gangrene, such as cabbage leaves and cayenne.”

    • Azuran

      I can’t understand how you could seriously google treatment for gangrene. How can you so far gone that you can believe your kid has freaking gangrene and not rush to the hospital?

      • EmbraceYourInnerCrone

        The same way the lady in labor for days and leaking meconium was asking the Internet for advice instead of calling an ambulance/having someone driver her to the hospital. Why do people think the advice of random strangers online is better/safer than going where they can get help from an actual doctor?? I view it as some sort of delusion but I honestly don’t know.

        I don’t think doctors are infallible, but I do think that most doctors are trying to do whats best for their patients and doctors study for YEARS to become professionals in their fields. But somehow some people still think hospitals and doctors are some sort of “conspiracy”

    • Heidi

      I was hoping it wasn’t a new case, that it’d be that couple that let their child die of meningitis a couple of years ago in Calgary. But nope. . .:(

    • Who?

      Poor little fellow, sick for weeks, probably in pain. Hard to imagine that anything involving cayenne pepper is going to be comforting to a sick child.

  • Anna

    The last sentence is the most correct and the sentence I hope will be the final message for Australian Mothers. If you have a baby at home, and something goes wrong YOU will be blamed. It doesn’t matter how negligent the midwife was, it doesn’t matter how uninformed or misled you were. It doesn’t matter if the midwife gives you homeopathics while you bleed to death or if she goes outside to smoke and calls the hospital and lies to them. The lay person Mother will be blamed. And we deserve blame. We know that. We get that. We do blame ourselves. We live with our choices every day. And we know that the same people that convinced us it was safe continue to do so and other women will make the same choices because our stories are not told.
    I know Sarah Kerr personally. She reached out to me after the death of my baby even though I had treated her terribly by supporting Lisa Barrett. She is a kind, compassionate, smart person I am honoured to call my friend. I don’t know where I’d be without her support. I know Lisa well too and was part of Janet Fraser’s homebirth cult. I had my second baby at home with Lisa and everything went fine. I thought she was magic. I didn’t believe any of the negative things said about her until after I lost my baby (different state, different midwife – no exact negligence involved). Finding out about what she did to Sarah was like finding out my favourite Uncle was a murderer. But I KNOW Sarah is telling the truth. I know because I was also told a whole lot of crap by Lisa and I believed her. I also believed I was so educated with my Hannah Dahlen articles and Midwife Thinking blog and the studies I’d read on homebirth that showed it to be safe. I didn’t know what I didn’t know. Its a cult. Its a religion. If you DARE question you are out.
    Theres so much that wasn’t included in this case. I find it ridiculous that Sarah’s evidence given 3 weeks after the death of her son was accepted as more truthful even though she admitted she lied. She lied to protect Lisa and the second midwife who were two of her best friends. It wasn’t until later she found the evidence of negligence. The second midwife also perjured herself in 2012. She was on FB last night, hours after the verdict gloating.
    The outcome was not unexpected though. It was always going to be very tough to meet the burden of proof for manslaughter. I hope more information becomes public in time. That was what this is really all about. Getting these babies stories told. Hoping that no-one else will have to go through a tragedy like this again. Lisas supporters are already out crowing – telling lies and I fear this will embolden her to start practising again. I put it out there that if everyone chooses to blame the Mothers then the same things will keep happening over and over. We need to show Mothers that there is no magic that will keep them safe, we need to make sure they are getting CORRECT info about homebirth and midwives cannot be trusted to do this. We need Drs and OBs to be more willing to really LISTEN to women and help them understand why they are not good candidates for homebirth. The entire culture around birth needs to change. Everyone here knows that. And if the Dahlens and Reeds and Byroms of the world actually gave a shit they’d be trying to educate women and make hospital birth better in any way they can, not just trying to get homebirth regulations relaxed.

    • MainlyMom

      I’m so sorry for your loss. Dr. Amy has been trying to fight the lisa barretts of the world for more than a decade, but former homebirthers are sometimes the best people to engage and educate those considering home births. I hope if it’s helpful or healing for you, That you’ll join this effort.

    • Anj Fabian

      Barrett was sidelined for at least a year. That much was an accomplishment.

      Now if we could something about Dahlen. She’s all about protecting the sisterhood at the expense of the public welfare.

  • Anj Fabian

    What I dislike most about the judge’s decision is that it leaves a huge loophole for midwives. As long as they can convincingly argue that their client was utterly committed to having a home birth and had been given some information as to the risks, the midwife can avoid criminal conviction by arguing that her client could not be swayed.

    You don’t have to prove that you made a serious effort to persuade your client or that they fully understood the risks they were taking, just that you made a token effort, checked the box.

    Ms. Kerr asked Barrett about the previous twin death and Barrett responded that the complication was rare and there was nothing to worry about. Complications involving the second twin aren’t rare and are something to worry about.

    Midwife lied to you? Not a problem for the midwife.

    • Anna

      Exactly. I have seen midwives on line making the exact claim “if my client has done her research its not up to me to tell her no – its my job to support her wishes”. The “surprise” twin Midwife in Melbourne claims her client made an informed choice. The Mother still has no idea how dangerous it was to have ID twins at home. No Vit K, no vaccines etc etc because these midwives tell the women they aren’t necessary, don’t work etc. Yes, the Mothers are partly to blame, but these are registered trained professionals! In Lisa’s case she had JUST handed in her rego and was telling everyone she was exactly the same person, just without a piece of paper.

      • MainlyMom

        My stepkids were surprise at hime twins. No one in their family to this day realizes how risky it was. All’s well that ends well is the takeaway.

      • Anj Fabian

        She got that right “she was exactly the same person, just without a piece of paper.”

        She’s always been willfully reckless. The only difference that piece of paper made was that she had one less thing to worry about.

  • Heidi

    So if Lisa was able to tell the mother there was a high risk the baby would die, then why did Lisa agree to it? In this case, there was definitely a safer alternative. If someone hands me a gun loaded with one bullet and asks me to pull the trigger with the gun pointed at their head but no worries, they understand there’s a one in seven chance they could die, I still think in this scenario if I kill them I am culpable and a murderer. Even if they said, well, I’m going to kill myself anyway. This to me is essentially what Barrett is doing. By accepting these patients, I think it sends the message that she believes these women are low risk, when everyone but maybe the shoulder dystocia would have been considered high risk, at least I presume. “I’m not in favor of it, but sure, I’ll take your money!”

    • Vast

      It’s a little more nuanced than that because presumably the midwife assumes that the mother/baby have a higher chance of dying with a freebirth than a homebirth w/ midwife. So the midwife could look at it as… either I pull the trigger with one bullet loaded somewhere into the gun or she pulls the trigger on herself with two bullets loaded. Not saying I think it’s the ethical choice (I’m not sure), but it’s complicated.

      • FormerPhysicist

        Right, but as people have pointed out here before, it seems that freebirthing may be less dangerous, because mothers (and fathers) will call for emergency transport and actual medical care earlier if something starts to go wrong.

  • Cartman36

    I cannot imagine how any mother can say she is willing to risk her child’s death for anything. I just don’t get it at all with Lisa or the mother. The only victims here are those poor babies.

    • rational thinker

      Sadly some home birth moms are fine with the risk to the baby. The thing with those moms is that it was never about the baby to begin with it is just about mom having bragging rights. A live baby would just be a bonus.

      • Cartman36

        “it was never about the baby to begin with”. You are right. It is just so different from how I approached having children. I wanted the baby not an experience.

        • rational thinker

          I just wanted my children too, and to be honest the last trimester totally sucks. These assholes just want a pregnancy and a birth not so much the kid.

        • AnnaD2013

          Amen amen!!!

      • Mel

        I do think some of it is the human denial that bad things can happen to them.

        Sam’s mom wrote about how she thought the OBs were being overly dramatic and anti-natural childbirth when they warned her that 1)twin home births are a bad idea and that 2) her babies were poorly placed for the second twin to survive a vaginal birth. She then doubled down by deciding that no one could have saved Sam in a hospital – or that he would have been severely compromised in the process. The sheer number of second twins born in hospitals without complications to babies or mothers – let alone deaths – implies her belief is motivated by denial of the horrific truth that Sam’s death was completely avoidable.

        I see it when people (frequently women) inform me that they couldn’t deal with all the medical/developmental things my son has. Sorry, kiddo; it’s not that easy. My son wasn’t born at 26 weeks because I’m a superwoman who can handle anything. My son was born at 26 weeks – and I dealt with the resulting chaos.

        • Ozlsn

          I agree with the human capacity for denial that they are not immune from bad outcomes thing. Almost no one goes into their first pregnancy thinking they might be the 1 in 250 who develops HELLP Syndrome, or even the 1 in 20 who develops preeclampsia. Everyone is going to have a perfect term pregnancy with a healthy baby at the end – and often they do. We listen to the good stories, and exempt ourselves from the warnings. Those things happen to other people – right up to the point they happen to us.

          Also I seriously am over people saying they couldn’t cope with x/y/z that you’re coping with. You (er, general plural you here, not Mel specifically) cope because seriously, what are the options here? No one is superwoman, and we all lean heavily on what support networks we can pull together. And I hope you have some good support Mel.

        • rational thinker

          I agree most do have the mentality of that wont happen to me. Sam’s mom has to keep telling herself that even a hospital could not have saved him. Because if she does admit that yes he would have been fine if she had gone to hospital to have the twins then she has to deal with the guilt the rest of her life that she basically let her child die a very preventable death.

        • rational thinker

          ” when people (frequently women) inform me that they couldn’t
          deal with all the medical/developmental things my son has”. –
          I hear that particular comment all the time cause my daughter is severely autistic and needs supervision every second of the day.
          I always tell them of course you can its a situation you have to deal with and the special care just becomes your new normal.

    • Lurker

      I may not say it all the time, but I do actually say it sometimes, and I certainly do it all the time. So do you, I’m sure. We let our kids climb to the top of the monkey bars even if there’s a tiny chance they’ll fall off, land on their heads, and die. I think the benefit outweighs the risk to their lives. More to the point, I drive my kids in the car just about every day. I do this even when the benefit probably doesn’t outweigh the risk – to get a tricky infant to fall asleep, or just to go to Target or the library because it would be nice to get out of the house. But in our society, in our culture, driving in cars is so normal that it doesn’t register as particularly risky, even though we’re all aware that car accidents exist, and even though, intellectually, I know they’re a top cause of death for children. I suspect that for a lot of people who are fully immersed in natural birthing subculture, homebirth has become just a normalized, to them, as driving in a car is to the rest of us. They may know the risks exist, but it doesn’t “feel” risky, so they don’t avoid it to prevent risking their children’s lives any more than the rest of us skip a trip to Target because it’s safer for our kids not to get in the car.

      • Mel

        The problem with most risky behaviors is that the negative consequences either pay out on a random schedule or separated by enough time that humans struggle to make the connections. To steal Bofa’s example, the vast majority of drunk drivers get home without killing themselves or anyone else – but when they don’t, the consequences are horrific. Similarly, my grandfather was a functional alcoholic and chain smoker for most of his life and died in his eighties – but that’s no comfort to the family of a 32-year old I know who died of alcoholic cirrhosis or anyone with lung cancer.

        Most childbirths will go just fine in the absence of trained medical help – but man, when the shit hits the fan, the consequences are horrific for the family involved. The problem is that so many births are in hospitals where medical staff prevent or resolve a ton of medical issues without parents noticing that homebirthers are left with a skewed view of safety from hospital births plus the statistically tiny group of people they know who birth at home….

        • Cartman36

          Exactly! After I had baby # 1 via c-section, my OB told me the reason she didn’t attend VBACs is because most of the time things go fine but when they don’t, they are catastrophic. This is why I never attempted VBAC with my future babies.

      • Cartman36

        I let my kids play on monkey bars because all the information that I have tells me its very unlikely to collapse. If multiple experts tell me that a particular set of monkey bars are unstable and might collapse I wouldn’t let my kids play on that particular set. Everything has risk but we have to use the information we have to decide what is an acceptable risk.

        • Lurker

          I used the monkey bars example because, in real life, that’s the kind of thing where I’m most likely to think “OMG, he climbed so high, he could fall on his head and die!” – but I bite my tongue and accept the small risk to his life because I think there are benefits to being able to climb monkey bars, experience some risk, etc.

          The car example was more pertinent – the risk to riding in a car is not insignificant. And we do it anyway, all the time. And even though, intellectually, I know that it’s just about the riskiest thing my kids ever do, I never get in the car and think, “Well, my kids could die, but I accept the risk because it’s really important to [get to work; get to the doctor; find a cute new top at Target].” It’s such a normal aspect of life that most people (myself included) DON’T consider the available information to decide whether the risk is acceptable – whether in day to day behavior or in making major life decisions. We don’t think “Fatalities in buses are much less common than in cars, but taking the bus to work every day would add half an hour to our commute each way, and I think the risk to my kids’ life is worth the extra hour in our day” when deciding whether or not to buy a car. Driving is too normalized in our culture for people to do that – even though we’re all aware that the risks exist, and I’d wager that every adult in the US can name someone who was killed in a car accident. What I guess I’m getting at is that I can understand how these women – even the ones who can name other babies who have died in homebirths – can acknowledge that the risks of homebirth exist, but still not bother to take them into consideration when it doesn’t *feel* risky to them because they exist in a subculture where it has been so extensively normalized.

          (I mean, not even once did I consider the life safety risk profile of cars vs buses before we bought our last car, despite the fact that the whole reason we’d spent a month riding the bus was because our previous car had been totaled in an accident with my toddler in the back seat. (I did consider the environmental impact, though. Felt guilty about it but got the car anyway.))

    • Ayr

      Women like that it is all about the bragging rights. ‘Look at me! Look at what I did! Oh by the way I got a baby out of it.’ There is a woman I was friends with a long time ago, we don’t speak anymore, she started going to into labor at 24 weeks, almost lost her daughter. She was sewn up, and put on bed rest for the remainder of the pregnancy. Her doctor told her she was high risk and may have the baby before 37 weeks and needed to have a bag packed and ready for the hospital. She told him flat out, she was not giving birth in a hospital, she was having a home water birth. He tried to reason with her, but she refused to listen and the doctor terminated her care, which she was totally ok with. Anyway week 38 she goes into labor, I get a text from her husband that her labor has stalled and even the midwife is trying to get her to go to the hospital but she won’t listen. She eventually delivers the baby, not sure how they got her labor started again, but she nearly lost the child and was totally ok with that, she even bragged about it. A few years later she pulls the same crap with her second child and the same thing happens. Women like her do not care about the children they are bringing into the world, just their experience, they are narcissists.

      • rational thinker

        Exactly! Remember when the blogger with that free birth website openly admitted that a healthy living baby is not everybody’s goal. These women are sick in the head, but most of them probably think I should not be a mother because I refuse to breastfeed.

        • Ayr

          Oh I know how you feel, I’m about to have my second (and last) child via c-section (my son was elective), I formula fed my son, my daughter will be formula fed. For some reason the idea of breastfeeding always gave me the willys. I had friends judging me because I admitted as much. A healthy living baby should always be the end goal of pregnancy not some trending fad to make ourselves feel better.