Finding into death of Tangimama Tavai

Contributing factors

• Postpartum haemorrhage
• Cervical tear with ongoing bleeding
• Possible transfusion-related acute lung injury (TRALI)
• Induction of labour scheduled outside normal working hours on Sunday evening
• Unclear escalation pathways and criteria for mandatory consultant attendance
• Registrar did not request consultant attendance when postpartum haemorrhage became apparent at 4.48am
• Multiple antenatal risk factors: grand multiparity, BMI >35, smoking, pregnancy-induced hypertension
• Intrapartum factors: augmented labour with syntocinon, precipitate labour once established, compound presentation

Coroner's recommendations

1. Recommend that Safer Care Victoria advises all maternity services to develop and implement institution-specific policies that include triggers for mandatory escalation to and attendance by senior medical staff for postpartum haemorrhage and other obstetric emergencies
2. Review of induction of labour (IOL) procedure to ensure it contains clear guidelines and sets out a process where consideration is given to risk factors by staff scheduling women for IOL, particularly when out of hours and/or on the weekend
3. Review of IOL procedure to include specific triggers for escalation to senior members of staff
4. Notify the consultant anaesthetist of any patient being managed for postpartum haemorrhage
5. Consideration by the organisation of rostering an obstetrician in support of the continuous delivery service and review all options for consultant rostering and attendance that best serves existing and future clinical requirements, or alternatively develop triggers for mandatory attendance of consultants (for example, when >1.2 litres of postpartum haemorrhage)