AN INQUEST INTO THE DEATH OF CORRINA ANNE MEDWAY
Deceased
Corrina Anne Medway
Demographics
32y, female
Date of death
2011-05-22
Finding date
2015-12-18
Cause of death
massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin
AI-generated summary
A 32-year-old woman with Factor V Leiden mutation died from a massive postpartum intracerebral haemorrhage of hypertensive origin five hours after delivering twins. She had been diagnosed with pregnancy-induced hypertension on 13 May and treated with labetalol, which was ceased on 16 May despite borderline elevated readings. On 19 May postpartum, her blood pressure escalated rapidly to 189-197 systolic/88-112 diastolic between 18:00-19:00 hours accompanied by chest, epigastric, and shoulder pain. Dr F. attended at 18:00 hours, recognized dangerously high systolic pressure (189/90), but attributed it to pain and administered only morphine. No antihypertensive treatment was given despite clear clinical indication. Expert evidence (Professor Brennecke) established that prompt antihypertensive therapy within a 2-hour window could have prevented the haemorrhage. The coroner found Dr F. failed to treat acute pregnancy-induced hypertension between 18:00-18:30 hours, directly contributing to her death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to recognize acute severe postpartum pregnancy-induced hypertension
- failure to administer antihypertensive treatment between 18:00-18:30 hours on 19 May 2011
- cessation of labetalol medication on 16 May despite indication to continue
- misattribution of hypertension to pain rather than pregnancy-induced hypertension
- lack of awareness or application of SOMANZ and WHO guidelines for hypertension in pregnancy
- inadequate clinical integration of observations by junior doctor (Dr L.)
- failure to read observation charts documenting escalating blood pressure
Coroner's recommendations
- All nursing staff, midwives, general practitioners, and specialist obstetricians involved in treatment and care of pregnant women undertake specific training on pregnancy-induced hypertension (pre-eclampsia) and associated risks antenatally and postpartum, including familiarity with SOMANZ and WHO guidelines
- Pre-eclampsia Foundation literature describing risks be provided by practitioners to all pregnant women under their care
- Patient's complete notes should be sent with the patient at time of discharge from birthing suite to ward
- Contemporaneous note-taking be routine and encouraged for all staff treating patients when significant events occur, including medical staff
Further listening
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