Health Ombudsman v Oliver - [2025] QCAT 362

QUEENSLAND CIVIL AND
ADMINISTRATIVE TRIBUNAL

CITATION:

Health Ombudsman v Oliver [2025] QCAT 362

PARTIES:

HEALTH OMBUDSMAN

(applicant)

v

STEPHANIE KATHLEEN SUSAN OLIVER

(respondent)

APPLICATION NO/S:

OCR047-24

MATTER TYPE:

Occupational regulation matters

DELIVERED ON:

21 October 2025

HEARING DATE:

28-30 July 2025
Applicant’s written submissions filed on 2 September 2025
Respondent’s written submissions filed on 23 September 2025
Applicant’s written submissions in reply filed on 29 September 2025

HEARD AT:

Brisbane

DECISION OF:

Judicial Member Robertson
Assisted by:
Ms C Ashcroft
Ms F Banwell
Dr J Toohill

ORDERS:

THE TRIBUNAL ORDERS THAT:

1.     The non-publication order made by the Tribunal on 23 July 2025 relating to the identification of the respondent is set aside.

IT IS THE DECISION OF THE TRIBUNAL THAT:

1.    Pursuant to s 107(2)(b)(iii) of the Health Ombudsman Act 2013 (Qld) (‘HO Act’), the respondent has behaved in a way that constitutes professional misconduct.

2.     Pursuant to s 107(3)(a) of the HO Act, the respondent is reprimanded.

3.     Pursuant to s 107(3)(e) of the HO Act, the respondent’s registration is cancelled.

4.     Pursuant to s 107(3) of the HO Act, the respondent is disqualified from applying for registration as a nurse or midwife for a period of two (2) years from the date of this order.

5.     There be no order as to costs.

CATCHWORDS:

PROFESSIONS AND TRADES – HEALTH CARE PROFESSIONALS – OTHER HEALTH CARE PROFESSIONALS – where the respondent was a registered midwife – where the respondent was involved as the secondary midwife in a planned home birth – whether the respondent and/or her colleague failed to respond to many concerning fetal heart rate auscultations late in the second stage of labour – where the baby was born floppy and unresponsive – where the baby never recovered and died three days later of severe hypoxic encephalopathy (brain damage due to lack of oxygen) – whether the respondent failed to provide intrapartum care to mother and baby at the standard expected of an experienced midwife – where the father of the baby videoed the labour and birth – where the respondent and her colleague altered the clinical records after the baby had died – whether in so doing the respondent acted dishonestly – where the respondent denies any misconduct – where the respondent gave evidence at a Coronial Inquest – where it is alleged that in providing the altered records to the Coroner the respondent was intending to mislead her – where each party relied on expert evidence – whether the applicant Director has proved that the respondent’s conduct amounts to professional misconduct – what is the appropriate sanction – where the respondent was a very experienced midwife at the time of the home birth – whether the respondent has demonstrated insight and/or remorse for her part in the home birth – where the respondent’s colleague admitted her misconduct and surrendered her registration in the wake of damming findings by the Coroner – where disciplinary proceedings involving her had been finalised recently in the Tribunal on the papers – whether the respondent’s registration should be cancelled

Coroners Act 2003 (Qld) s 39

Health Ombudsman Act 2013 (Qld) s 107
Health Practitioner Regulation National Law (Queensland)

Queensland Civil and Administrative Tribunal Act 2009 (Qld) s 66(2)

Briginshaw v Briginshaw (1938) 60 CLR 336

Health Ombudsman v Blyth [2025] QCAT 161

Nursing and Midwifery Board of Australia v Fankhauser [2013] QCAT 395

APPEARANCES & REPRESENTATION:

Applicant:

S Amos instructed by Corrs Chambers Westgarth

Respondent:

Self-represented

REASONS FOR DECISION

The respondent, Stephanie Oliver, is an experienced and highly qualified midwife who remains registered with the Nursing and Midwifery Board of Australia (‘Board’). As at 9-10 January 2018 she was practising as a midwife and as a Director of My Own Midwife GC (‘MOM’) at Ashmore on the Gold Coast. She had been employed in that position since February 2013.
On the night of 9 January, and into the early hours of the morning on 10 January, the respondent was involved as the secondary midwife in a planned home birth. The primary midwife, Rosemary Blyth (‘Blyth’), was also a Director of MOM and a very experienced midwife.
Patient A was 39 years of age at the time of the birth. She had had two previous children in hospital and had decided on having a home birth for her third child. In June 2017, she engaged MOM, a private provider of midwifery services including home births, and Blyth was engaged in the antenatal care of Patient A.
The respondent was contacted by Blyth on 9 January, and she attended Patient A’s house at 11:20pm at which time she was in labour. A second midwife is required to attend any home birth.
A baby girl, Patient B, was born at approximately 3:40am on 10 January. She was very pale, floppy and unresponsive with the umbilical cord around her neck. During the attempted resuscitation of Patient B that followed her birth, the respondent was unable to adequately manage Patient B’s airway and to ventilate her. The Queensland Ambulance Service (‘QAS’) was called to attend at 3:44am.
The ambulance officers intubated and ventilated Patient B and she was transferred to the Gold Coast University Hospital (‘Hospital’). She was diagnosed with severe hypoxic encephalopathy (brain damage due to lack of oxygen). It is common ground that the cord around her neck played no part in her suffering brain damage. She was pronounced dead at 6:40pm on 13 January 2018.
A Coronial Inquest was held in May 2021 at which Blyth and the respondent both gave evidence under the protection of s 39 of the Coroners Act 2003 (Qld), so that any evidence given by the respondent is not admissible in these proceedings.
In her findings delivered on 17 September 2021, the Coroner was highly critical of both midwives, both in relation to the exercise of professional care to Patient A and Patient B, but also in relation to their credit. For reasons that I will expose, in relation to the respondent, based on the evidence in these proceedings, I agree substantially with the findings of the Coroner.
On 29 September 2021, the Health Ombudsman received a notification from the Coroner’s Court attaching the findings concerning the conduct of the respondent and Blyth in relation to the intrapartum care of Patient A and Patient B, and on 21 October 2021 the father of Patient B, who was present throughout and videoed the birth, also made a complaint to the Health Ombudsman referring to the findings of the Coroner.
On 29 February 2024, the Director of Proceedings on behalf of the Health Ombudsman (‘applicant’) referred the matter to the Tribunal for determination. The referral alleges that the respondent has engaged in professional misconduct which relates to two allegations.

Allegation 1

Allegation 1 is that the respondent failed to provide intrapartum care on the night of 9-10 January 2018 to Patient A and Patient B to the standard reasonably expected of a registered midwife. The factual allegations in support are not contested.
Allegation 2 is that on or about 14 January 2018, following the death of Patient B on 13 January 2018:
(a)the respondent knowingly and dishonestly altered and/or fabricated parts of the MOM Labor Progression Notes of the birth of Patient B (the clinical records); or
(b)alternatively, was complicit in the dishonest alteration and/or fabrication of the records, and knowingly provided false information to the Coroner.
It is not disputed that the respondent and Blyth amended the clinical records on 14 January 2018.
The respondent has represented herself throughout these proceedings. She cooperated with the applicant in agreeing to a substantial Statement of Agreed and Disputed Facts (‘SADF’). She appeared at the hearing over three days (28-30 July 2025) via Starlink from a remote part of Western Australia, where she is presently on an extended road trip with her husband.
She did not file an affidavit in these proceedings. The record will reveal that she was given extensive information about her rights, and she elected to give evidence and be subjected to cross-examination. She struck me as a highly intelligent person who was acutely aware of the nature of the allegations. To enable her evidence to be placed conveniently before the Tribunal, after she was affirmed she adopted the factual allegations in her response and submissions as her evidence in chief, which she supplemented with some short oral evidence. She was cross-examined over many hours. She strongly denies any misconduct.
By way of background, her colleague Blyth surrendered her registration as a midwife in November 2021 effective from 14 December. She was also referred to the Tribunal in separate proceedings which were determined on the papers on 15 April 2025.
On 15 December 2021, the Health Ombudsman imposed conditions on the respondent’s registration which remain in place. At the time the registration action was taken, the respondent was working as a senior clinical midwife at the Hospital. In her submission, she states that she is travelling Australia and that:[1]
since ceasing employment [with the Hospital] in 2022, [she] has been unable to secure employment as a midwife due to the allegations made by the Health Ombudsman.
[1]Submissions on Behalf of the Respondent, filed in the Tribunal 24 January 2025, 3 [6].
This was not explored in cross-examination.
The applicant bears the legal responsibility of proving the allegations to the civil standard, subject to the application of the sliding scale referred to in Briginshaw v Briginshaw (1938) 60 CLR 336. The allegation in the referral relating to the clinical records contains allegations of dishonesty, and for that reason the Tribunal will proceed on the basis that the standard of proof in this case should be at the higher end of that sliding scale.
The father recorded the birth and critically the events leading up to 3:40am on 10 January. He used a phone to record the labour and birth and as well, he had a fixed inside camera facing the balcony of their Gold Coast apartment. As well as the three video recordings tendered as part of the hearing brief, other part videos were tendered by the applicant during the hearing. The assessors and I have listened to and watched the three recordings in the hearing brief. Records 9 and 11 (Documents 39 and 41) are of quite high quality.
Two very experienced midwives gave evidence before the Tribunal. Marie Heath gave evidence before the Coroner. She provided a report to the legal representatives of Blyth dated 13 May 2021.[2] She gave her opinion which was favourable to Blyth on the basis of a video which she described as ‘not high quality or lighting and the sound is very poor in places’ and a transcript (prepared by the father) which she described in her report as ‘unreliable’.[3] Notwithstanding these difficulties, she provided an opinion that Blyth had ‘followed appropriate assessment and provided care as would be expected of any reasonable midwife’.[4] In her report to the lawyers she stated (based on what she saw and heard based on the video she was given) that the fetal heart rate (‘FHR’) auscultations taken by Blyth were in accordance with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (‘RANZCOG’) Guidelines for the second stage of labour.[5]
[2]Contained in the Hearing Brief, filed in the Tribunal 17 March 2025, 746-755.
[3]Ibid 747.
[4]Ibid 749.
[5]Ibid 748.
In her evidence to the Coroner, she completely resiled from her earlier opinion after hearing the evidence of Blyth. She said that the auscultations were not appropriate or in accordance with the applicable guidelines. However, she said that it was not always practical in a clinical setting to adhere strictly to guidelines. In that evidence she agreed with the evidence of Dr Allen, a consulting obstetrician and gynaecologist who gave evidence before the Coroner that the auscultations were not appropriate because:
(a)they did not commence up to 60 seconds after the end of a contraction;
(b)they were consistently of an insufficient length throughout the labour;
(c)there was no auscultation in the last eight minutes of labour; and
(d)Blyth was calling out numbers that bore no resemblance to the audible auscultations.
She was also critical of the failure to take action upon detection of significant FHR abnormalities.
Despite this, the respondent called her to give evidence in her case.
Surprisingly, in her evidence in chief before the Tribunal, Registered Midwife (‘RM’) Heath again adopted her original report except in relation to her opinion about the timing of the call to QAS. She was not directly challenged about this in cross-examination. To be fair to Counsel for the applicant, she covered most of the topics covered in cross-examination before the Coroner, and effectively, the witness seemed to return to the position her evidence was in at the end of her evidence before the Coroner. It may be that with the passage of time, she had forgotten the concessions she made before the Coroner, and it is not known what material she had available to her when she began her evidence before the Tribunal.
It is apparent that the RANZCOG Guidelines that she used in her report were not in force at the time of the incident. The version that was in force (the 2014 version), recommended, among other things, that each FHR auscultation should commence toward the end of a contraction and be continued for at least 30-60 seconds after the contraction has finished, and fetal and maternal heart rates should be differentiated whatever the mode of monitoring used. The National Institute for Health and Care Excellence Guidelines for Intrapartum care for healthy women and babies specify that intermittent auscultation (‘IA’) of the FHR for a woman at low risk of complications established in the first stage of labour should be carried out after a contraction for at least one minute, at least every 15 minutes.
The video of the labour shows that a number of IAs occurred for less than 30 seconds. It is not obvious from the video that there was an instance when the maternal pulse was correlated at the time of an IA. The clinical records indicate that only two maternal pulse rates were taken at 3:19am and 3:35am. This later entry was inserted in the clinical records on 14 January.
In cross-examination, RM Heath was taken through the video of the birth which she accepted was very clear. She accepted that a number of auscultations were below 30 seconds and conceded these did not comply with the guidelines.
She agreed that after listening to the video there were a number of abnormal FHRs after 3:10am, and that these abnormalities were indicators of potential fetal distress. She accepted that between 3:21am and 3:27am there was a sinusoidal pattern in the FHRs audible on the hand-held Doppler device which can be a significant indicator of fetal compromise. She accepted that the clinical picture in its totality did not provide any reassurance that, even if the birth was imminent, Patient B was not compromised.
She accepted that a midwife of her experience and training can identify a Doppler reading simply by hearing it, and, in effect, she made similar concessions to those she made to the Coroner. In re-examination, she seemed to backtrack again.
The applicant is very critical of RM Heath in its final submission. That criticism is justified but I am not prepared to find that her evidence was ‘demonstrably untrue’ as the applicant suggests, as that serious proposition was never put directly to the witness. It is very concerning that a professional witness should provide such erratic accounts on different occasions.
I think it is highly likely that the witness was not prepared for her evidence before the Tribunal. Usually, expert witnesses are required to state clearly the facts that they considered in forming their opinions because unless those facts are proved the opinion is worthless. This topic was not explored. It is not even clear if she had access to the report of RM Betts-Hendy.
The respondent submits that RM Heath has much more recent clinical experience than her colleague which is correct. It is even more surprising that such an experienced midwife would provide an opinion to a Coroner based on what she describes as a poor quality video of the birth and an unreliable transcript, then retract that favourable opinion when challenged before the Coroner, and then revert to her original opinion some years later before this Tribunal before, once again, reverting to her final position before the Coroner.
The applicant called RM Betts-Hendy, a very experienced midwife, to give expert opinion evidence in its case. Ms Betts-Hendy was engaged by the solicitors for the applicant to give opinion evidence about the respondent’s professional conduct during the labour and birth and her actions subsequently.
It is correct as the respondent submits in her final submission that RM Betts-Hendy has not practiced as a home birth midwife since she came to Australia. She was first registered in Western Australia in 1991. However, her extensive CV attached to her report indicates that she is a highly credentialled Registered Nurse and RM with tertiary qualifications in midwifery and health sciences in the UK and Australia. In more recent times she has moved into high level leadership roles in health service provision and education.
RM Betts-Hendy explained in response to questions from the respondent that after her career in the UK, where she was involved clinically in home births, she came to Australia and found that home birth practice lacked governance or oversight. She explained that as part of her various roles in senior women’s and children’s health in NSW, she brought home birth practice into the governance structure that applied to home births conducted in a hospital setting.
In her final submission the respondent states:[6]
In her report RM Betts-Hendy expressed concern about my understanding of
the role of the second midwife stating:
The second RM’s comment in her statement to the coroner that her role was to “help during birth if requested” appears to demonstrate a complete lack of understanding of her role as second midwife. This care is substantially below the standard reasonably expected of a midwife.
However, nowhere in my statement to the coroner do I say this. In fact, at no time have I ever stated that that was all my role entailed.
[6]Respondent’s Closing Submissions, filed in the Tribunal 23 September 2025, 6 [25].
The respondent understandably as a layperson had difficulties in understanding the rules pertaining to cross-examination. I hope the record shows that she was given a great deal of latitude over objections from her opponent.
I explained to her very clearly that as a matter of fairness, particularly to an expert witness, if there was material in the evidence that undermines her opinion, then that should be put to the witness to give her a chance to explain.
It is correct that the words attributed to the respondent in this passage do not appear in the respondent’s statement to the Coroner, however the respondent did not ask her about this or give her a chance to explain. It is not clear therefore if those words or words to that effect appear in any of the other material that she had access to for the purposes of preparing her report.
The witness may have simply been mistaken in suggesting that those words came from the statement to the Coroner. When the respondent submits that ‘[i]n fact, at no time have I ever stated that that was all my role entailed’, while that may be literally correct, in other parts of her material, which formed her evidence before the Tribunal relating to what the applicant calls the ‘Invisible Practice’, she goes very close to saying exactly that albeit with different words.

The expertise of both witnesses was not challenged. For the reasons set out above, I readily prefer the evidence of RM Betts-Hendy to that of RM Heath.

Allegation 1

The facts particularised in the referral are admitted in the SADF. Importantly, as part of that document, the respondent admits (as she must, given the existence of the videos of the labour and birth) that the FHR was audible in the room from the hand-held Doppler device. The videos have enabled all the experts in the Inquest and RM Betts-Hendy and RM Heath in these proceedings to independently listen to the various auscultations and discern the FHR as if they were present during the labour and birth.
The failures of the respondent as the second midwife are particularised as follows:
On 10 January 2018, the respondent failed to provide intrapartum care to Patient A and Patient B at the standard expected by reason of the following:
(a)      from 3:10 onwards, or alternatively from 3:21am, following a FHR of 77bpm, the respondent failed to recognise FHR anomalies which she should reasonably have identified based on the FHR audible via the doppler machine;
(b)     from 3:10am onwards, or alternatively from 3:21am, the respondent did not question or correct FHR readings called by [Blyth], which she should have been aware were incorrect based on her knowledge and experience and what was audible via the doppler machine;
(c)      from 3:10am onwards, or alternatively from 3:21am, the respondent failed to adequately respond to FHR anomalies in that she did not increase her active monitoring of the birth and her assessment of the wellbeing of Patient A and Patient B;
(d)     the respondent failed to monitor FHR at any stage during the labour and delivery, in particular during the last few minutes of the delivery when [Blyth] was attending to the birth, which contributed to there being no auscultation of the FHR for approximately 8 minutes prior to the birth of Patient B;
…
In her response, the respondent addresses these four particulars in this way:[7]
My role at the birth was as the second healthcare provider, to assist the primary midwife when requested and be available in case of obstetric or neonatal emergencies.
[Blyth] is an experienced midwife and has attended many births. I was not supervising or observing her practice. It was our practice for the second health care provider to be out of the way and almost “invisible” to the clients.
[7]Response and/or counter application, filed in the Tribunal 2 May 2024, 2.
This was her primary position in relation to Allegation 1, maintained in her final submission. In her response and submissions, she also ‘distanced’ herself from the actions of her colleague.
A normal FHR is between 110-160bpm. In accordance with the agreed facts, of the ten auscultations taken between 3:10am and 3:32am, six were abnormal.[8]
[8]Submissions on Behalf of the Applicant, filed in the Tribunal 22 November 2024, 3-4 [14], [15]-[20].
As is agreed, Blyth auscultated the FHR using an audible hand-held Doppler device, and ‘called’ the reading for the respondent to record in the clinical records contemporaneously. The respondent agreed that the FHR was ‘audible in the room from the [Doppler] device’.[9] It is also common ground that an experienced midwife is able to tell from hearing the FHR whether or not it is normal.
[9]Statement of Agreed and Disputed Facts, filed in the Tribunal 9 July 2024, 5 [22].
There was some focus in the hearing on a FHR audible on the Doppler at 3:10am as 77bpm, but recorded in the clinical notes as 134bpm. As the SADF notes, this FHR was based on a 17 second auscultation and the FHR appeared to recover to a normal rate for the last two seconds prior to the auscultation being discontinued. It is common ground that such a FHR is indicative of fetal distress. The respondent says that she ‘has no recollection of hearing a fetal heart rated of 77bpm at 3:10am’. In her submission, she says she was ‘at the other side of the room to resume the role as scribe’. She says that she was in this position from 3:06am until just after 3:26am when she stood up to assess what was happening as Patient A had a contraction. The respondent says that the first low FHR that she heard was at 3:28am, which was called by Blyth as 77bpm and recorded in the clinical notes as 95-125bpm.
The respondent’s primary position (i.e. as an almost ‘invisible’ second health care provider, or as a ‘scribe’), was heavily criticised by the applicant in its trial submission in which it is described as the ‘Invisible Practice’.
The applicant’s criticisms are based on the expert opinion of RM Betts-Hendy. In relation to a number of issues, she fairly conceded that in the clinical environment, strict adherence to recommended guidelines may not be achievable, but in relation to the primary position of the respondent as to her understanding of her role, the expert did not depart from her many criticisms of the respondent’s professional conduct as the second midwife as set out in her trial report.
She explains that the role of the second midwife includes providing support, continuing maternal and fetal observations, providing information (in this case) to the principal midwife, receiving Patient B (if not placed on the mother), and managing resuscitation and any emergency requirements. She emphasises that the provision of safe fetal and maternal care is always paramount. She explains in her report that the second midwife should:[10]
(a)have situational awareness;
(b)be aware of anomalies;
(c)view all information in an objective way;
(d)provide expertise to minimise harm; and
(e)have the experience to intervene, seek assistance, and plan for problems, as required.
[10]Affidavit of Ms Betts-Hendy, sworn 22 August 2024, Exhibit SLH-3.
After the filing of her Response, the SADF and the opinion of RM Betts-Hendy, the respondent provided information to the applicant for it to consider before it filed its trial submission including a letter from the respondent to the Health Ombudsman dated 12 November 2024. From the applicant’s trial submission, it can be inferred that in that letter the respondent described the ‘Invisible Practice’ as not good when it comes to risk management, and she acknowledged that she should have known that at the time.[11] This prompted the applicant to recognise that the letter indicated a developed insight and remorse into the events of the night.
[11]Submissions on Behalf of the Applicant, filed in the Tribunal 22 November 2024, 7 [50].
I infer that after the respondent received the applicant’s trial submission, she retracted the letter and its admission was left to be determined by the Tribunal at the hearing. The applicant did not press for the admission of the retracted letter at the hearing and did not bring it to my attention until late on day three to enable me to deal with it then. I do not understand the rather desultory submission made by the applicant in its final submission to strongly press for the admission of that letter as some form of admission by the respondent. In those circumstances, I will not consider the letter further.
The admitted facts focus on the period from 3:10am to the birth at 3:40am and the subsequent attempted resuscitation, calling of QAS, the death of Patient B and the alteration of the clinical notes on 14 January.
It is common ground that:
(a)IA is an appropriate method of fetal monitoring in women without recognised risk factors;
(b)it is essential that an accurate record of fetal wellbeing is maintained. The fetal and maternal heart rates should be differentiated;
(c)each auscultation should commence toward the end of the contraction and be continued for at least 30-60 seconds after each contraction has finished; and
(d)each auscultation should be undertaken and documented after each contraction for at least every five minutes in the active stage of labour.
Confining her opinion to the stage of labour leading up to birth described in the SADF, I accept the opinion of RM Betts-Hendy that IA was not performed correctly or recorded accurately; none of the audible discrepancies were questioned by the respondent, and despite FHR anomalies, neither midwife initiated increased surveillance nor responded appropriately as professional midwives, for example, by seeking obstetric advice or calling QAS. I accept her opinion that there appeared to be little recognition by either midwife that there were significant anomalies with the FHR for at least 30 minutes before birth. I also accept her opinion to this effect:[12]
Even if the [FHR] monitoring during the first stage had been reassuring…, the lack of IA during the last 8 minutes of the second stage is inexplicable. Standard practice requires monitoring of the [FHR] until the baby is born, this would include when there is a delay between birth of the head and body, as observed in this birth.
[12]Affidavit of RM Betts-Hendy, sworn on 22 August 2024, Exhibit SLH-3, 3.
These opinions accord with those of the consultant obstetrician and gynaecologist Dr Allen who gave evidence before the Coroner.
The respondent accepts that if she had heard a FHR of 77bpm at 3:10am she would have recognised this as a significant indicator of fetal distress. She says that she has no recollection of hearing this. As noted above, in the clinical notes she has recorded this FHR as 134bpm.
She accepts that as an experienced midwife, in January 2018, she should have been able to determine the FHR just by hearing it. This accords with all the expert evidence and is confirmed by the professional assessors both of whom are themselves highly qualified and experienced midwives. She accepts that she should be able to detect bradycardia and tachycardia just by hearing the FHR.
As above,[13] she agrees that the FHR was audible in the room. That is borne out by the videos, especially Document 9.[14] The video does not record (so that it can be heard) that Blyth called this abnormally low FHR at 3:10am. It is therefore unclear on what basis the respondent recorded a normal FHR of 134bpm.
[13]See [43].
[14]Tendered as Exhibit 10 at the hearing.
As that agreed facts record, the FHR of 77bpm was based on a 17 second auscultation (as noted above this is well below the minimum guideline rate of 30 seconds), and that the FHR (as can be heard) appeared to recover to a normal rate for the last two seconds. The next three FHRs recorded (at 3:12am, 3:14am and 3:17am) were all within normal range and are correctly recorded by the respondent in the clinical notes.
It is conceivable that, by adopting the ‘Invisible Practice’, the respondent may not have heard the abnormally low rate at 3:10am. As against that, if she did not hear that rate, for whatever reason, she was able to hear the correct rates (four in all) from 3:12-3:19am. From 3:21am there are a number of abnormal FHRs which are audible on the video:
(a)At 3:21am, the actual FHR is 88bpm. It is recorded as 135bpm.
(b)At 3:23am, the actual FHR is 200bpm, called as 140bpm, recorded as 140bpm.
(c)At 3:27am, the actual rate is 90bpm, called as 112bpm and recorded as 140bpm.
(d)At 3:28am, the actual rate is 77bpm, called correctly but recorded as 95-125bpm (this last figure was added by the respondent and Blyth on 14 January).
She says this FHR of 77bpm was the first abnormal rate she recalls. Despite this, and bearing in mind that she has to accept that as an experienced midwife her training would enable her to detect such an abnormal FHR simply by listening, she has incorrectly recorded the FHR in the clinical records. At 3:32am, the actual FHR was 94-95bpm, called correctly but recorded as 115bpm. Even on the respondent’s own case, at this point she was near the birthing pool.
The FHR was not auscultated again prior to birth at 3:40am. The clinical records suggest that three further auscultations were taken. The experts all agree by listening to the video that these three auscultations were not taken.
The particulars of Allegation 1 (a)-(d) were amended by leave at the commencement of the hearing to allow for the possibility that the Tribunal would accept that the evidence did not establish that the respondent ought to have heard and responded to the FHR of 77bpm at 3:10am. It is really only the respondent who says she has no recollection of hearing that concerning heart rate at 3:10am. In my view, it matters little (in the context of a disciplinary proceeding) that the respondent’s failure to provide intrapartum care to Patient A and Patient B was from then or from 3:21am.
I have formed a poor impression of her credibility, particularly relating to my findings in relation to Allegation 2. It seems inconceivable to me, that despite apparently being able to hear and record accurately the FHRs from 3:12-3:17am, all of which were within the normal range, the only rate she does now not recall hearing prior to that is the very abnormal rate of 77bpm at 3:10am. She says now that she did not hear the abnormal rates from 3:21-3:27am. I do not accept her evidence to that effect.
As an experienced midwife she must have understood from at the latest 3:21am, that there was real potential for fetal compromise. Her position that she was a mere ‘scribe’, or the so-called ‘Invisible Practice’ might explain the discrepancies in the notes and her failures, but in accordance with the expert evidence, which I prefer over hers, this practice itself fell substantially below what was expected of her. Her evidence, taken at its best, does not, in any event, explain why she recorded FHRs that were wrong and called wrongly by her colleague and/or called correctly and recorded incorrectly.
It is now agreed that no FHR auscultations were taken in the eight minutes leading up to the birth of Patient B. The clinical notes however record the following:[15]
3:33am     Head almost crowned, FH[R] 117.
3:35am     FH[R] 109 Mat pulse 80.
3:37am      Head almost out. FH[R] 80.
[15]Hearing Brief, 577.
It is common ground that these entries were not recorded by the respondent at the time but were entered by she and Blyth on 14 January after Patient B had died at 6:40pm on 14 January. These entries are critical to the elements of Allegation 2 but are also relevant to Allegation 1. Even on the respondent’s own evidence, she was definitely not acting at this time (i.e., from 3:33am) as a mere ‘scribe’. She was present at the birthing pool and actively assisting her colleague. She says now that she only agreed to those entries being made on 14 January because her colleague assured her that these had occurred. Her evidence cannot be accepted.
Accepting that Blyth was primarily engaged with assisting Patient A to give birth at this stage, it was probably physically difficult for her to actually auscultate the FHR using the handheld Doppler device. The expert evidence that I prefer, is that the failure to auscultate the FHR in these critical eight minutes renders this failure alone as conduct that fell substantially below what was required. The respondent never at any stage auscultated the FHR. It simply defies logic and common sense to suggest that if Blyth had undertaken the three auscultations, the respondent would not have observed and heard that happen given her proximity to the birthing pool at that time. It is disingenuous for her now to suggest that when they amended the records on 14 January that she only involved herself and agreed with her colleague because she believed her.
I find the failures alleged in particulars 1.23(a)-(d) of the application to have been proved to the requisite standard.
Particular 1.23(e) alleges a failure to transfer Patient B to the resuscitation area in a timely fashion.
It is clear from the video that Blyth was panicking at this stage. She had to be told to get a stethoscope by the respondent, and contrary to accepted practice, Blyth cut the umbilical cord using only one clamp instead of two, with the consequence that considerable blood flowed into the birthing pool. Given the very poor condition of Patient B at birth, the very concerning signs leading up to the birth, and the failure by both midwives to auscultate the FHR in the critical eight minutes prior to birth, it should have been immediately obvious to the respondent that this was an emergency. She should have taken Patient B immediately to the resuscitation area; instead, as RM Betts-Hendy observes, the focus was on stimulation and the actions of Blyth.
Particular 1.23(g) alleges that the respondent failed to ensure that there was an adequate light source in the resuscitation area, or an adequate heat source to keep the lower extremities of Patient B warm. I accept RM Betts-Hendy’s evidence that the light source as seen in the video was inadequate because the light above the resuscitation area was dim and cast a shadow over Patient B, making it more difficult to see results of air entry and respiratory efforts. The respondent agreed in cross-examination that there was a desk lamp that could have been used, but she maintained that the light was adequate. She also agreed that no blanket or other item was used to keep Patient B’s lower extremities warm in what was an emergency situation. This conduct should not be considered in isolation. If it was, the fact that it was an emergency might explain why these details weren’t covered. Given the many failures of both midwives to this point, I am satisfied that this particular, based on my acceptance of the evidence of RM Betts-Hendy, is proved to the relevant standard.
There was much discussion about Patient B’s Apgar score at birth and her heart rate. In my opinion, none of this factual dispute requires resolution. I accept the expert evidence that a patient in such poor condition should have been taken immediately to the resuscitation area. Particular 1.23(h) relates to the failure to call the ambulance in a timely fashion. I accept the expert’s evidence that the ambulance should have been called when the patient was born at the very latest. I accept her evidence that the failures of the respondent in this regard were to some extent caused by Blyth’s failures as the primary midwife, but this does not excuse the respondent. The respondent clearly was very proactive in trying unsuccessfully to ventilate and resuscitate Patient B, but her actions in commencing these attempts were too late.

Allegation 2

In the amended application, the applicant alleges the failures of the respondent as follows:[16]
[16]Amended Application on Behalf of the Applicant, filed in the Tribunal 24 July 2025, 12 [2.1]-[2.6].
(a)The applicant relies on the same background facts relied upon to support Allegation 1.
(b)A Coronial Inquest into the death of Patient B was conducted at Southport Coroners Court on 18-19 May 2021 and 23-24 August 2021 before Deputy State Coroner, Jane Bentley (‘Coroner’).
(c)The respondent and Blyth provided the MOM records to the Coroner.
(d)On or about 14 January 2018, the respondent knowingly and dishonestly altered and/or fabricated the MOM records, or, alternatively, was complicit in the dishonest alteration and/or fabrication of those records in, at least, the following respects:
1.   the alteration of the record of the FHR (listed in MOM records as at 3:28am) from 94-95bpm to ‘95-125bpm’;
2.   the alteration of the record of the FHR at 3:30am from 77bpm to ‘115bpm’ (or, alternatively, the fabrication and insertion of the FHR as 115bpm);
3.   the fabrication and insertion of a FHR at 3:33am when no auscultation occurred;
4.   the fabrication and insertion of a FHR at 3:35am when no auscultation occurred; and
5.   the fabrication and insertion of a FHR at 3:37am when no auscultation occurred.
(e)The respondent did not ensure that a copy of the original MOM records were retained and did not ensure there was a proper audit trail in relation to the alterations alleged in 77(d) herein.
(f)The respondent knowingly provided the false records referred to in 77(d) herein to the Coroner.

I have already referred to some extent to the factual findings relating to this allegation in the reasons above.
Even the most cursory examination of the records indicate that the respondent’s evidence alleging that these actions were the product of her colleague’s honest recollection, cannot be true.
Firstly, if the amendments were honest, proper standards require that the record as it existed before being amended should be retained for future audit. This was not done.
Secondly, the three critical entries (at 3:33am, 3:35am and 3:37am) said by the respondent to be the product of Blyth’s honest recollection relate to auscultations that we now know from examination of the video evidence simply did not happen. At the time these clearly false amendments were made, the respondent and her colleague could not have anticipated that the video of the birth, taken by the father, would readily enable other experts, including very experienced and credentialled midwives like themselves, and Dr Allen before the Coroner, to state categorically that such auscultations did not occur. As noted above, even on the respondent’s own account, she was no longer ‘across the room’ or acting as a ‘scribe’ at this critical time. She was right there, and any auscultation taken by Blyth should have been seen and heard by her. In her final submission, the respondent submits that:[17]
128. At the time, I believed she was accurately documenting her true recollection of events. It was both reasonable and accepted practice for me to rely on her recollection, especially in the immediate aftermath of a rapidly unfolding, traumatic birth.
[17]Closing Submissions of the Respondent, filed in the Tribunal 23 September 2025, 32 [128].
In my opinion, the respondent is being deliberately dishonest and/or disingenuous. The alterations were not made in the aftermath of the birth. They were made some days later after Patient B had died.
Thirdly, at this time (i.e. on 14 January 2018), when the records were amended, Patient B had died. At the latest, at 3:21am (on the evidence that I have accepted), there had been a series of alarming FHRs which, on the evidence of the expert which I accept, should have alerted both midwives to the real possibility of dangerous fetal distress and caused them to act to protect both Patient A and Patient B. The three impugned entries give an entirely different picture of a normal heart rate immediately prior to birth.
As RM Betts-Hendy states, there is no problem in adding to clinical notes after the event, provided that the additions are true, and the fact that they were added retrospectively is clearly stated.
The entire amendment in the records after ‘QAS called by Rosie …’, with the exception of agreed fact 48(b), was entered by the respondent and Blyth on 14 January 2018. In the body of that entry, are these words:
On entry 10/1/18 3:28 hrs - I added “- 125bpm” after “FH 95” as that was my clear memory of the foetus’ heart rate at this time.
There is no mention in that retrospectively added entry of the other three entries in the clinical records immediately after this entry (i.e. the three notes in agreed fact 48(b) (ii)-(iv)). It is now agreed that those three entries were made by the respondent and her colleague at the same time as the entry ‘QAS called by Rosie …’.
These were fictitious entries made by the respondent and Blyth to protect themselves. At the very least, the respondent was complicit in the dishonest alteration of the clinical records.
The respondent did not refer to these dishonest alterations in the records when she made her statement to the Coroner. She now says that this is because she was responding to a notice to Blyth to provide information about the birth, and she had been asked by Blyth to assist her. I have rejected her evidence that she believed that the three entries of the FHRs just prior to birth were the honest recollection of her colleague when they altered the records on 14 January 2018 after Patient B had died.
As I have noted, she is clearly an intelligent person. She must have appreciated the importance of providing the Coroner with every relevant detail within her knowledge. As I have noted, the three impugned entries would have given the impression to any reader, including the Coroner, that just prior to the birth the FHR was within normal range. Her colleague amended her statement to the Coroner at the start of her evidence and admitted that these were false entries, ‘to falsely reflect that the FHRs were taken appropriately and accurately’. The respondent sadly maintains her clearly dishonest recollection which I reject.
Allegation 2 is proved to the requisite standard.

Sanction

The principles relating to the discretionary power of this Tribunal to sanction health practitioners who have been found to have engaged in professional misconduct are well known and need not be restated. The paramount guiding principle is that the safety and health of the public are paramount. The purpose of sanction is to protect and not to punish.
The proved conduct the subject of both allegations is extremely serious. The respondent’s failure (along with her colleague) to respond to clearly audible FHRs, indicative of potential fetal distress, for a significant period of time prior to the birth, involves a substantial departure from the relevant standards expected of such an experienced midwife. The adoption of the so-called ‘Invisible Practice’ may have been a reason, but that approach in itself involved a substantial departure from expected relevant standards, because it may have contributed to the respondent failing to respond when she should have, to audible indicators of fetal distress. RM Betts-Hendy did speculate that fatigue may have been a factor contributing to the impugned conduct of both midwives, but the respondent has never suggested that she was over-tired or fatigued when she was at the home. As the Coroner notes in her findings:
76. She [the respondent] said she does not recall being fatigued at the time of the birth even though she agreed that she’d had only two hours sleep before being awoken to attend.
Her proved conduct in relation to Allegation 2 involves a substantial departure from the standards expected of nurses and midwives to be open and honest when communicating in respect of adverse events. I accept the submission made by the applicant that the respondent’s proved conduct in relation to the alteration of the clinical records and knowingly providing false information to the Coroner ‘was wholly inappropriate, dishonest and inconsistent with her being a fit and proper person to hold registration’.
Conduct of this kind has the clear tendency to undermine public trust and confidence in her profession. Midwives are intimately involved in providing health services to mothers and babies, and such a serious departure from professional standards in this case should be met with a stern sanction to:
(a)discourage others from engaging in similar conduct; and
(b)uphold public trust in such a vital profession.
The respondent has demonstrated little or no insight into the seriousness of her conduct. For that reason, specific deterrence is applicable even though the events the subject of the referral occurred just under seven years ago. This is relevant now to risk. Having noted the effluxion of time, the respondent’s conduct in relation to the Coroner occurred in 2021, and that experience, which was obviously traumatic for her, has not caused her to reflect on her conduct.
The respondent has helpfully summarised the many testimonials that she has filed. It is not surprising that a midwife who has had a long and fulfilling professional career is able to muster many favourable references. The difficulty is that none of these people have provided a reference on the basis of proof of the alleged conduct in the referral.
The respondent has a relevant disciplinary history. Complaints were received initially by the Health Ombudsman in 2017 relating to alleged failures in the clinical care of a mother and baby involving a delayed referral, inappropriate monitoring and a missed or incorrect delayed diagnosis relating to a pregnancy and birth on 20 November 2015. The matter was ultimately referred to the Board and on 12 October 2018 after considering material before it, the Board decided to caution the respondent.
What is very relevant to this referral are the comments made by the Board in its decision:
The Board acknowledged that Mrs Oliver has undertaken further education and training for her professional practice in response to concerns identified by the independent opinion. Mrs Oliver has also advised she has changed her practice significantly as she is now a more defensive practitioner, is more cautious and more aware of risks, is undertaking more investigations, is acting sooner and now has a lower threshold for referring a patient to hospital.
The Board’s decision was made in the same year as the events the subject of this referral. The Board’s comments seem to derive from submissions made to it by the respondent both before and after the events the subject of this referral.
I agree therefore that the respondent’s conduct as proved here demonstrates that her advice to the Board was without substance.
It is important, as a matter of public policy, that there be consistency in outcome for like cases across the various disciplinary regimes in Australia. I have considered and read the comparable decisions referred to in the submissions.
The matter of Nursing and Midwifery Board of Australia v Fankhauser [2013] QCAT 395 is directly comparable. It concerned the failures of a midwife at a Gold Coast Hospital to appropriately monitor and respond to FHR readings, including a failure to call a medical specialist. The respondent in that case then altered records when she knew that the death was to be investigated by the Coroner. She knowingly gave false and misleading information to hospital administration regarding the performance of her duties.
That hearing before the Tribunal was on the papers. The respondent did not contest the factual allegations and made admissions about characterisation and joined with the Board in joint submissions on sanction to include an order that she be disqualified from reapplying for registration for 18 months. By the time of the hearing, the practitioner had surrendered her registration. There were jurisdictional issues identified by the Tribunal which are not relevant here. Subject to certain undertakings being given by the practitioner and accepted by the Board to overcome these issues, the Tribunal indicated its support for the jointly proposed sanction.
The recent on the papers decision involving Blyth[18] is clearly directly comparable. There are a number of distinguishing features of her case.
[18]Health Ombudsman v Blyth [2025] QCAT 161.
She accepted an additional allegation that she had failed to provide antenatal care to Patient A at the standard expected of a registered midwife between 4 and 9 January 2018. As the primary midwife from MOM, she was aware of important information concerning Patient A in the period leading up to the home birth.
The other relevant distinguishing feature is that Blyth made full and comprehensive admissions about her failures and agreed to the characterisation and orders by way of sanction. She had surrendered her registration following the delivery of the findings of the Coroner. She was found to have expressed appropriate remorse and shame for her failures to provide appropriate care to both Patient A and Patient B, and for her dishonesty in relation to the alteration of the records and her response to the Coroner. She was reprimanded and disqualified from applying for registration for a period of two years.
In my opinion, and taking into account the distinguishing features, the appropriate response is an order similar to that made in relation to her colleague.
Non-publication Order
On 28 March 2024, the Tribunal made an order prohibiting the publication of material that could identify or lead to the identification of Patient A, or any member of her family, Patient B’s father or any member of his family, and any other patient of the respondent.
That order remains in place. On 23 July 2025, the respondent applied for an order prohibiting the publication of information that could identify or lead to her identification, and the Tribunal made an interim order to that effect.
The respondent has not provided any evidence addressing any of matters referred to in s 66(2) of the Queensland Civil and Administrative Tribunal Act 2009 (Qld). For example, she does not suggest any relevant adverse consequences to her mental or physical health relating to the important public interest in having open proceedings in matters such as this. Not surprisingly, she has been very stressed by the protracted nature of these proceedings, but her evidence does not establish any good reason why her name should not be published for this reason.
The applicant opposes that making of a final non-publication order, and relevantly points to the Blyth decision which mentions the respondent as being one of the attending midwives.[19]
[19] Health Ombudsman v Blyth [2025] QCAT 161, [4(a)].

Orders

THE TRIBUNAL ORDERS THAT:

The non-publication order made by the Tribunal on 23 July 2025 relating to the identification of the respondent is set aside.

IT IS THE DECISION OF THE TRIBUNAL THAT:

Pursuant to s 107(2)(b)(iii) of the Health Ombudsman Act 2013 (Qld) (‘HO Act’), the respondent has behaved in a way that constitutes professional misconduct.
Pursuant to s 107(3)(a) of the HO Act, the respondent is reprimanded.
Pursuant to s 107(3)(e) of the HO Act, the respondent’s registration is cancelled.
Pursuant to s 107(3) of the HO Act, the respondent is disqualified from applying for registration as a nurse or midwife for a period of two (2) years from the date of this order.
There be no order as to costs.