Coroner's Finding: Rebecca Murray
Deceased
Rebecca Murray
Demographics
29y, female
Date of death
2007-06-25
Finding date
2009-06-12
Cause of death
Multisystem organ failure following postpartum haemorrhage due to atonic uterus
AI-generated summary
Rebecca Murray, 29, died from multisystem organ failure following postpartum haemorrhage after an emergency caesarean section at Bathurst Base Hospital on 24–25 June 2007. The coroner found her death preventable. Key clinical failures: (1) Hospital policy of not ordering pre-operative blood group/hold/cross-match for emergency caesareans, resulting in delayed transfusions; (2) Inadequate handover from theatre to recovery—the recovery nurse was not informed of blood loss or uterine tear repair and had never managed postpartum haemorrhage; (3) Failure to recognise and escalate the emerging haemorrhage promptly, with a 30+ minute delay contacting the surgical team leader. The coroner identified systemic failures rather than individual blame: hospital policy gaps, inadequate nursing training, poor handover procedures, and insufficient experienced obstetric nursing staff. Recommendations focused on implementing uniform pre-operative blood testing for all caesarean sections across NSW.
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 conduct full blood count, group and hold prior to emergency caesarean section
- Hospital policy of not ordering pre-operative cross-matching
- Inadequate handover from operating theatre to recovery room
- Recovery nurse not informed of blood loss during surgery or uterine tear
- Recovery staff lacked experience and training in postpartum haemorrhage management
- Failure to check fundal height or perform fundal massage in recovery
- Failure to recognise and escalate continuing post-partum bleed promptly
- Delayed escalation to surgical team—over 30 minutes before contacting obstetrician
- Atonic uterus—failure of uterus to contract effectively
Coroner's recommendations
- Implement a uniform policy in all New South Wales hospitals requiring a full blood count and group and hold be undertaken for all elective and emergency caesarean sections (formal recommendation to the Minister for Health).
- The Director General of NSW Health to give specific consideration to issues identified in this death, particularly: obstetric training standards, postpartum haemorrhage guidelines, and availability of haemostatic drugs such as Misoprostol and Novoseven in NSW hospitals.
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