Finding into death of THI DIEP ANH LU
Deceased
THI DIEP ANH LU
Demographics
36y, female
Date of death
2012-11-20
Finding date
2015-10-20
Cause of death
Haemorrhage complicating elective caesarean section (placenta praevia accreta)
AI-generated summary
Ms. Thi Lu, aged 36, died from massive hemorrhage following caesarean section for placenta praevia with underlying placenta accreta. Although imaging could not definitively exclude accreta preoperatively, high-risk preparations were made. During surgery, when the placenta proved morbidly adherent with severe hemorrhage, the initial consultant chose conservative management with Bakri balloon tamponade and initially declined to call for additional senior surgical help. After approximately 10 minutes' delay, a second consultant was called and emergency hysterectomy was performed, but the patient arrested before hemorrhage could be controlled. The coroner acknowledged the extreme difficulty of the situation but identified a key clinical lesson: immediate escalation and hysterectomy upon recognizing massive hemorrhage and anatomical complexity, rather than attempting conservative measures, would have offered the best chance of survival. The case highlights the imaging limitations in diagnosing placenta accreta and the critical importance of senior surgical escalation protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Placenta accreta with morbid adherence to previous uterine scar from two prior caesarean sections
- Initial failure to appreciate catastrophic nature of hemorrhage
- Delay in calling for additional senior surgical assistance
- Attempted conservative management with Bakri balloon tamponade rather than immediate hysterectomy
- Massive ongoing hemorrhage with coagulopathy and shock
Coroner's recommendations
- RANZCOG Women's Health Committee should highlight in the 'Placenta Accreta' guideline that high-risk pregnancies should be managed on the assumption that placenta accreta exists, with patient, surgeon, and anaesthetist all prepared for immediate hysterectomy with possible massive blood transfusion
- The surgeon should be prepared for rapid referral to an additional senior surgeon for decision on the need for and implementation of immediate hysterectomy
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