Home Birth death

http://www.timesonline.co.uk/tol/news/uk/health/article3934513.ece

There are some very worrying facts about the reporting of this story.
The coroner specifically blames the midwife's hesitation for Joanna Whale's death. Yet the evidence as reported suggests that this hesitation was only part of the cause: a significant error was the breakdown of communication between medical staff at the hospital which lead to doctors assuming - rather rashly, I would have thought - that Joanna had a retained placenta.
Better communications in the hospital might have saved Joanna's life yet the coroner blames the home birth for her death. If the midwife had had more experience in home birth management, this too might have helped save Joanna's life. The coroner does not seem to see this and instead simply assumes that the home birth situation is at fault.
The story is reported next to another court story about another young mother who died in childbirth, after a routine C-section because of placenta praevia, in hospital. Why didn't the coroner warn of the dangers of C-sections in hospital as a result?
The Joanna Whale story smacks of witch-hunting.

Angela Horn, owner of the Homebirth UK website, writes:

"This is the first maternal death after planned home birth that I'm aware of in the UK, in the past 30 years or so. This is despite theUK having around 15,000 planned home births a year, IIRC. The UK's average maternal death rate is 1 in 10,000, of which many are women who had caesareans. As planning a homebirth roughly halves the numbero f women who end up with caesareans, it would be interesting to calculate the number of women's lives which have been saved by planning homebirth over the years..."