An inquest into the death of Corrina Anne Medway [2015] ACTCD 3 required consideration of the circumstances leading to the death of Ms Medway, who had a prothrombin gene mutation giving rise to a tendency of her blood to clot. For this she was taking a low dose of aspirin. She also had a family history of maternal hypertension and during her pregnancy had some blood pressure issues.

Following findings (adverse to the attending obstetrician at [250], [251] and [260]), the coroner made four recommendations at [264], focusing on pre-eclampsia and record keeping:

A. That all nursing staff, midwives, general medical practitioners and specialist obstetricians involved in the treatment and care of pregnant women undertake specific training with respect to pregnancy induced hypertension (pre-eclampsia) and the risks that condition presents to pregnant women antinatally and post partum. This training should include familiarity with the SOMANZ guidelines in place at the time and the WHO recommendations regarding treatment and care of patients with pregnancy induced pre-eclampsia.

B. That literature such as the Pre-eclampsia Foundation Brochure (which sets out the risks of pre-eclampsia to pregnant women) be provided by practitioners who have the care and treatment of pregnant women to all pregnant women under their care.

C. That a patient’s complete notes should be sent with the patient at the time of their discharge from the birthing suite onto the ward.

D. The taking of contemporaneous notes is to be encouraged when any significant event occurs. In my view this should be routine for all staff treating a patient, including the medical staff.

 

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