Inquest into the Death of Laura Marguerite Sinclair

Contributing factors

• Amniotic fluid embolism
• Uterine hypotonia/atony
• Heavy post-partum haemorrhage (estimated 4 litres total blood loss)
• Failure to perform coagulation studies despite massive blood loss
• Failure to fully communicate patient's unstable vital signs to consulting obstetrician
• Failure to appreciate severity of patient's condition by emergency doctor inserting cannula
• Lack of Medical Emergency Team (MET) activation despite clinical triggers
• Delayed recognition of amniotic fluid embolism as differential diagnosis
• Inadequate communication regarding patient's critical status to receiving facility (KEMH)
• Transfer to inappropriate facility without intensive care ventilation capacity

Coroner's recommendations

1. Implementation of 24-hour Medical Emergency Team (MET) with pre-determined clinical triggers to enable nurses to escalate care independently of treating consultant
2. Increased clinician awareness of amniotic fluid embolism as differential diagnosis in post-partum haemorrhage, particularly with coagulopathy features
3. Full blood count and coagulation screening should be undertaken immediately after significant post-partum haemorrhage to guide transfusion management
4. When consulting obstetricians are telephoned regarding unstable patients, they should make active enquiries about clinical observations if information is not fully registered
5. Treating obstetricians should clinically assess deteriorating patients rather than relying solely on emergency department doctor performing limited procedures
6. Improved communication protocols between referring and receiving hospitals regarding patient acuity and critical care requirements