Coronial
NThospital

Inquest into the death of Linda Nha Tran

Deceased

Linda Nha Tran

Demographics

34y, female

Date of death

2010-06-02

Finding date

2011-09-09

Cause of death

Catastrophic post-partum haemorrhage following caesarean delivery, secondary to placenta accreta

AI-generated summary

A 34-year-old Vietnamese woman died from catastrophic postpartum haemorrhage following an elective caesarean delivery. Placenta accreta was discovered intraoperatively and managed with blood transfusion, uterotonic agents, and a Bakri balloon. Dr L. administered prostaglandin F2α at an excessive dose (3mg in two separate doses minutes apart, rather than the guideline dose of maximum 3mg in three separate doses 10-15 minutes apart) to a haemodynamically unstable patient. Within minutes, the patient arrested, requiring hysterectomy and ICU admission. She developed multi-organ failure with irreversible shock and died. Key clinical lessons: ensure clear communication between surgical and anaesthetic teams during obstetric emergencies; the anaesthetist was not informed of prostaglandin administration; haemodynamic instability and prior vasopressor use should be documented and communicated to senior colleagues; verify correct drug dosing protocols before administration; earlier surgical intervention may improve outcomes in massive PPH secondary to placenta accreta.

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

Specialties

obstetricsanaesthesiaintensive caremidwifery

Error types

medicationcommunicationdelay

Drugs involved

oxytocinmisoprostolprostaglandin f2αmetaraminoladrenalinenoradrenaline

Clinical conditions

post-partum haemorrhagemassive postpartum haemorrhageplacenta accretahypovolaemic shockcardiac arrestmulti-organ failurepulmonary oedemadisseminated intravascular coagulationmetabolic acidosis

Procedures

caesarean sectionmanual removal of placentabakri balloon insertionbimanual uterine compressionhysterectomycardiopulmonary resuscitation

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
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