Finding into death of Mary Anna Powlina Korzeniewski
Deceased
Mary Anna Powlina Korzeniewski
Demographics
37y, female
Date of death
2004-12-29
Finding date
2013-09-17
Cause of death
Hypoxic brain injury complicating cardiorespiratory arrest during manual removal of placenta (under spinal anaesthetic) following postpartum haemorrhage in the presence of a patent foramen ovale
AI-generated summary
A 37-year-old primigravida with gestational diabetes was admitted for labour induction at 37 weeks. Following vaginal delivery and delayed placental separation, manual removal of placenta was performed under spinal anaesthesia. The patient suffered sudden cardiorespiratory arrest with profound ST changes and ventricular fibrillation. Resuscitation was prolonged; she regained output but sustained irreversible hypoxic brain injury and died three days later. The coroner determined the cause was an embolic phenomenon (amniotic fluid or air embolism) facilitated by a patent foramen ovale, rather than postpartum haemorrhage or anaesthetic complications. Blood loss was adequately managed and documented; fluid resuscitation was appropriate; spinal anaesthesia was appropriate. Clinical lessons include: meticulous vital signs documentation with timelines; clear handover communication between care teams; and awareness that catastrophic peripartum collapse may result from non-preventable embolic events despite appropriate management.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- patent foramen ovale facilitating embolic passage
- manual removal of placenta
- spinal anaesthetic
- opportunity for amniotic fluid or air embolus entry during peripartum procedure
Coroner's recommendations
- The Royal Australian and New Zealand College of Obstetricians and Gynaecologists should explore the utility of developing, administering and maintaining an Amniotic Fluid Embolism register to capture incidents of AFE (including both deaths and survivals) with the aim of improving knowledge base and potentially management of women diagnosed with AFE
- Healthcare professionals should be reminded that documentation is a means of communication between treating professionals, is a legal document and should serve as an aide memoir
- Retrospective clinical notes should clearly indicate the date and time they are made to avoid the false impression of sequential documentation
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