Coronial
NSWhospital

Inquest into the death of Gia Lam

Deceased

Gia Lam

Demographics

32y, female

Coroner

Decision ofDeputy State Coroner Hosking

Date of death

2019-02-04

Finding date

2026-03-17

Cause of death

Sepsis due to pyelonephritis of the right kidney due to acute and chronic cystitis

AI-generated summary

A 32-year-old Vietnamese-speaking woman died from sepsis due to pyelonephritis following premature discharge from hospital onto a midwifery support program. Multiple missed diagnostic opportunities occurred: difficulty passing urine on 21 January was not investigated; abnormal urinalysis with erythrocytes +++ on 31 January was not escalated to medical review; and a 'very offensive smell' on 3 February was dismissed as hygiene rather than infection. Pain was inadequately documented, preventing recognition of evolving abnormality. No interpreter was used despite language barriers, compromising communication about symptoms. Discharge was inappropriate for a patient with undiagnosed UTI. The home visit midwife failed to recognise critical deterioration and advised self-referral to GP rather than calling an ambulance. Antibiotic treatment on 3 February would likely have prevented death.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

obstetricsmidwiferyemergency medicine

Error types

diagnosticcommunicationsystem

Clinical conditions

urinary tract infectioncystitispyelonephritissepsisinstrumental vaginal deliveryperineal tearpregnancy

Procedures

vacuum-assisted deliveryperineal repair

Contributing factors

  • failure to diagnose UTI on 21 January 2019 despite reported difficulty passing urine
  • failure to escalate abnormal urinalysis findings on 31 January 2019 (erythrocytes +++)
  • failure to recognise offensive odour as sign of infection on 3 February 2019
  • inadequate pain documentation obscuring abnormal pain trajectory
  • premature and inappropriate discharge on 3 February 2019 with undiagnosed UTI
  • failure to use accredited interpreters despite language barrier
  • failure to perform vital observations prior to discharge
  • failure to recognise critical deterioration during home visit on 4 February
  • advice to self-refer to GP rather than seek emergency care on 4 February

Coroner's recommendations

  1. SWSLHD should audit a sample of Standard Maternity Observation Charts or MOC Charts relating to CALD patients to determine whether observations are being documented and recorded correctly, including at the required frequency, depending upon the clinical acuity of the patient
  2. Nursing and Midwifery Board of Australia should review and/or investigate RM Khan's care of Gia during her maternity admission
Full text
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