Coroner's Finding: Rebecca Murray

29y · Female·Multisystem organ failure following postpartum haemorrhage due to atonic uterus

Rebecca Murray, 29, died from multisystem organ failure following postpartum haemorrhage after an emergency caesarean section at Bathurst Base Hospital on 24–25 June 2007. The coroner found her death preventable. Key clinical failures: (1) Hospital policy of not ordering pre-operative blood group/hold/cross-match for emergency caesareans, resulting in delayed transfusions; (2) Inadequate handover from theatre to recovery—the recovery nurse was not informed of blood loss or uterine tear repair and had never managed postpartum haemorrhage; (3) Failure to recognise and escalate the emerging haemorrhage promptly, with a 30+ minute delay contacting the surgical team leader. The coroner identified systemic failures rather than individual blame: hospital policy gaps, inadequate nursing training, poor handover procedures, and insufficient experienced obstetric nursing staff. Recommendations focused on implementing uniform pre-operative blood testing for all caesarean sections across NSW.