AN INQUEST INTO THE DEATH OF CORRINA ANNE MEDWAY

32y · Female·massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin

A 32-year-old woman with Factor V Leiden mutation died from a massive postpartum intracerebral haemorrhage of hypertensive origin five hours after delivering twins. She had been diagnosed with pregnancy-induced hypertension on 13 May and treated with labetalol, which was ceased on 16 May despite borderline elevated readings. On 19 May postpartum, her blood pressure escalated rapidly to 189-197 systolic/88-112 diastolic between 18:00-19:00 hours accompanied by chest, epigastric, and shoulder pain. Dr F. attended at 18:00 hours, recognized dangerously high systolic pressure (189/90), but attributed it to pain and administered only morphine. No antihypertensive treatment was given despite clear clinical indication. Expert evidence (Professor Brennecke) established that prompt antihypertensive therapy within a 2-hour window could have prevented the haemorrhage. The coroner found Dr F. failed to treat acute pregnancy-induced hypertension between 18:00-18:30 hours, directly contributing to her death.