Finding into death of Mary Anna Powlina Korzeniewski

37y · Female·Hypoxic brain injury complicating cardiorespiratory arrest during manual removal of placenta (under spinal anaesthetic) following postpartum haemorrhage in the presence of a patent foramen ovale

A 37-year-old primigravida with gestational diabetes was admitted for labour induction at 37 weeks. Following vaginal delivery and delayed placental separation, manual removal of placenta was performed under spinal anaesthesia. The patient suffered sudden cardiorespiratory arrest with profound ST changes and ventricular fibrillation. Resuscitation was prolonged; she regained output but sustained irreversible hypoxic brain injury and died three days later. The coroner determined the cause was an embolic phenomenon (amniotic fluid or air embolism) facilitated by a patent foramen ovale, rather than postpartum haemorrhage or anaesthetic complications. Blood loss was adequately managed and documented; fluid resuscitation was appropriate; spinal anaesthesia was appropriate. Clinical lessons include: meticulous vital signs documentation with timelines; clear handover communication between care teams; and awareness that catastrophic peripartum collapse may result from non-preventable embolic events despite appropriate management.