Inquest into the Death of Laura Marguerite Sinclair

31y · Female·Post-partum Haemorrhage associated with Amniotic Fluid Embolism and Uterine Hypotonia

Laura Marguerite Sinclair, 31-year-old primigravida, died from post-partum haemorrhage associated with amniotic fluid embolism (AFE) and uterine hypotonia. She underwent emergency caesarean section for foetal distress at Peel Health Campus, experiencing heavy blood loss (estimated 1500ml). Although initially stable post-operatively, she re-bled significantly (1000ml) within hours. Critical clinical opportunities were missed: coagulation studies were not performed despite massive transfusion requirements; Dr I. did not fully appreciate midwives' concerning vital signs when telephoned at 10:25pm and ordered transfusion without ensuring discontinuation of concurrent Syntocinon infusion; Dr K., when inserting a second cannula, was not adequately informed of the patient's hypotension and deteriorating condition; and no Medical Emergency Team (MET) was called despite clear clinical triggers. The deceased deteriorated into shock and was transferred to KEMH then emergently to Sir Charles Gairdner Hospital, where she arrested and could not be resuscitated. The coroner found the death arose from natural causes but identified significant communication and escalation failures.