Coronial
ACThospital

AN INQUEST INTO THE DEATH OF CORRINA ANNE MEDWAY

Deceased

Corrina Anne Medway

Demographics

32y, female

Coroner

Coroner Hunter

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. Report an inaccuracy.

Specialties

obstetricsgeneral medicineneurosurgeryemergency medicine

Error types

diagnosticmedicationdelaycommunication

Drugs involved

labetalolmorphineenoxaparinparacetamol/codeine

Clinical conditions

pregnancy-induced hypertensionpre-eclampsiapostpartum hypertensive crisisintracerebral haemorrhagefactor v leiden mutationprothrombin gene mutation

Procedures

vaginal delivery of twinsepidural analgesiaintubationCT scanningneurosurgery

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

  1. 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
  2. Pre-eclampsia Foundation literature describing risks be provided by practitioners to all pregnant women under their care
  3. Patient's complete notes should be sent with the patient at time of discharge from birthing suite to ward
  4. Contemporaneous note-taking be routine and encouraged for all staff treating patients when significant events occur, including medical staff
Full text
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Source and disclaimer

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