Finding into death of THI DIEP ANH LU

36y · Female·Haemorrhage complicating elective caesarean section (placenta praevia accreta)

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.