Inquest into the death of Linda Nha Tran

Contributing factors

• Placenta accreta not detected preoperatively
• Excessive dose of prostaglandin F2α (3mg administered as 1.5mg twice within minutes, rather than guideline maximum 3mg in three doses 10-15 minutes apart)
• Administration of prostaglandin F2α to haemodynamically unstable patient
• Failure to communicate prostaglandin administration to anaesthetist
• Inadequate communication between surgical and anaesthetic teams regarding haemodynamic instability and prior vasopressor use
• Delay in decision to proceed to hysterectomy
• Patient's small stature relative to blood loss

Coroner's recommendations

1. An agreed and documented protocol for the management of post-partum haemorrhage and other obstetric emergencies at ASH
2. Training of all birth attendants in the maintenance of post-partum haemorrhage management
3. A flow chart should be freely available in operating theatre and labour ward with clear dosage instructions for PGF2α in the emergency box
4. A laminated diagram showing how to insert a uterine compression suture should be available in operating theatre
5. A skills workshop in the management of obstetric emergencies (e.g. shoulder dystocia and PPH) should be conducted every 6 months
6. A process needs to be established with one designated person to communicate with laboratory staff in an efficient and timely manner
7. Review the timely provision of blood products from the laboratory; if relocation is not feasible, develop a process to address delays
8. Arrangements should be made to make more than one unit of platelets available at any time
9. Close formal links be established between ASH Senior Clinical Staff and a tertiary level hospital for readily available telephone and/or onsite advice
10. Multidisciplinary hospital drills in the management of massive obstetric haemorrhage should occur every twelve months involving obstetric, anaesthetic, midwifery, theatre, laboratory and ancillary staff
11. Multidisciplinary case review meetings between Obstetric and Anaesthetic Departments on a 6 monthly basis