Coronial
VIChospital

Finding into death of Linda Elizabeth Parker

Deceased

Linda Elizabeth Parker

Demographics

39y, female

Coroner

Deputy State Coroner Iain West

Date of death

2010-07-01

Finding date

2015-04-02

Cause of death

Hypoxic brain injury secondary to multiple hypovolaemic cardiac arrests from catastrophic haemorrhage due to placenta increta

AI-generated summary

Linda Parker, aged 39, died from hypoxic brain injury following catastrophic postpartum haemorrhage from placenta increta during caesarean delivery. Critical lessons: (1) Placenta increta risk was not detected prenatally despite three prior caesarean sections creating significant uterine scarring; ultrasound request forms lacked vital obstetric history, preventing targeted imaging; (2) Delayed decision to proceed to hysterectomy after discovering morbidly adherent placenta likely allowed development of disseminated intravascular coagulopathy and uncontrollable bleeding; (3) Earlier hysterectomy would probably have prevented coagulopathy and massive haemorrhage. The coroner highlighted importance of accurate prenatal diagnosis through proper clinical information on imaging requests, awareness of placenta accreta/increta risks with recurrent caesarean sections, and timely surgical decision-making in tertiary centres.

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

Specialties

obstetricsanaesthesiahaematologyintensive careneurologyneurosurgeryradiology

Error types

diagnosticdelay

Clinical conditions

placenta incretadisseminated intravascular coagulopathyhypovolaemic shockcardiac arresthypoxic brain injuryacute renal failureischemic limb injuryconsumptive coagulopathy

Procedures

caesarean deliveryhysterectomyuterine artery ligationlaparotomyexternal ventricular drain insertionmassive transfusion

Contributing factors

  • Failure to diagnose placenta increta prenatally despite high-risk history of three prior caesarean sections
  • Ultrasound request forms did not include vital clinical history of previous caesarean sections
  • Delay in decision to proceed to hysterectomy after diagnosis of morbidly adherent placenta, allowing development of disseminated intravascular coagulopathy
  • Accidental bladder perforation during hysterectomy
  • Massive transfusion protocol not activated

Coroner's recommendations

  1. Royal Australian and New Zealand College of Obstetricians and Gynaecologists develop a clinical guideline defining a clear pathway when placenta accreta is discovered or suspected, specifying that birth should occur in a place with necessary medical facilities and expertise
  2. Amend the 'Caesarean Delivery on Maternal Request' statement to include evidence of potential risks associated with recurrent caesarean sections
  3. Regional Imaging Gippsland Service re-design ultrasound request forms to include relevant clinical information regarding previous caesarean sections
Full text
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