Hospital blamed for mum's death
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Adam Cresswell, Health editor |
March 06, 2008
A YOUNG mother who went to hospital for a planned caesarean delivery of her third child died after facing problems that included staff failing to measure how much blood she was losing, not passing on details of her condition and blood-transfusion machines turning themselves off.
A NSW Health report into the death of Rebecca Murray, 29, found a blood-testing machine from the intensive care unit at Bathurst Base Hospital could not be used because staff were unfamiliar with it, did not have an access password and the wrong cartridges were supplied.
There was "inadequate information exchange" between staff as Ms Murray's blood pressure plunged after her operation, in which she gave birth to a healthy baby girl. And time was lost during her treatment because a pre-operative blood test - normally a requirement for patients undergoing spinal anaesthesia - had not been performed.
Within three hours of her caesarean, Ms Murray's condition deteriorated to the point where she was taken back into the operating theatre in a bid to locate the source of her bleeding. She suffered a cardiac arrest on the operating table, and despite being transferred to Nepean Hospital in western Sydney, died on June 25 last year.
Ms Murray's husband Jim, 41, appeared in a news conference at the NSW parliament organised by the state Opposition and contradicted the official explanation of his wife's death, which referred to her needing an "emergency caesarean".
"There wasn't an emergency until they waited - the GP on duty thought he could deliver it naturally until two hours later, when the baby was in fetal distress," he said. "She was doomed from the time she went through that hospital door."
The NSW Health report shows that contrary to hospital guidelines, no resuscitation team was called when Ms Murray's blood pressure plunged 30 minutes after her caesarean section. Fifty minutes after the operation, it had dropped to a "critically low level" of 54/22.
NSW Health Minister Reba Meagher said maternal deaths were "extremely rare", and the case was being investigated by the Health Care Complaints Commission and the coroner. "While this case is a tragedy, it should not be used to indict the whole health system," Ms Meagher said.
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