Deficiencies in pregnant Melbourne mum's healthcare before death
The last thing Melbourne mum Annie Moylan did before she died was miscarry her second child.
The 37-year-old died from multi-organ failure caused by a sepsis infection within hours of delivering her baby at 18 weeks, and less than 24 hours after falling ill in August 2017.
An inquest has examined potential hospital system failings which might have contributed to the death of Moylan, the mother of a 14-month-old son and a partner in a law firm.
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State Coroner John Cain didn't make any findings about the nursing or medical management she received at either Holmesglen Private Hospital or St Vincent's hospital.
But he found there were deficiencies in the care she received and there were several issues which warranted comment.
Medical experts gave varying opinions on whether Moylan could have survived with antibiotics at any stage of her treatment.
"The expert evidence… could only be described as unsettled," he said.
Moylan's greatest chance of survival would have been if antibiotics were administered by 8.30pm on August 14, he found.
By 10.15pm there was no nursing or medical management, including the administration of intravenous antibiotics, that could have prevented her death, he said.
The day she fell ill, Moylan left work early with gastroenteritis symptoms.
An obstetrician prescribed rest and paracetamol.
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She hadn't improved by the evening so went to the nearby Holmesglen Private Hospital in Moorabbin.
Hui Li Shi was the sole doctor responsible for the 10-bed emergency department that night and took more than an hour to see Moylan.
At 9.30pm she was feeling much better, but 45 minutes later Moylan was writhing in pain.
At that point Shi should have reconsidered her initial diagnosis and looked at sepsis as a diagnosis to exclude, Cain said.
"Dr Shi did not do this," Cain found, pointing to confirmation bias in symptoms supporting her initial diagnosis.
When Moylan's membranes spontaneously ruptured at 11.30pm, Shi believed her 40.3C temperature was causing a miscarriage.
Shi should have known gastro was not the likely cause and should have prescribed intravenous antibiotics, Cain said.
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Regardless of Shi not being aware of sepsis guidelines at the hospital, an emergency physician should be expected to be aware of the signs and symptoms, he said.
Moylan was taken to St Vincent's Private Hospital, where her obstetrician Dr Vicki Nott was supposed to meet her.
Shi said she told Nott about the urgency of Moylan's transfer.
But Nott said she didn't know it was a medical emergency and didn't arrive until an hour after Moylan. She sat in her car for 10 minutes researching antibiotics.
After raising a sepsis diagnosis at 1.45am, Nott then disappeared for 20 minutes and could not be contacted by midwives while searching for sepsis guidelines.
While a prescription for antibiotics was written at 2am, Moylan didn't receive her first dose until 2.46am.
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She only received them after midwife Raechel Miller spotted the medication sitting on a bedside table.
Nearly an hour after that first dose Miller found a second dose in the hospital room, but Moylan had already been transferred to theatre.
Nott should have prescribed the antibiotics at 12.40pm and they should have been administered within 15 to 30 minutes of being prescribed, Cain said.
She should have known which antibiotics to give, he said.
Miller and the midwife in charge, Gillian Codd, should be commended for their care of Moylan, Cain said.
Traumatised by her patient's death, Miller has since changed careers.
Moylan underwent surgery and received plasma and platelet transfusions but went into cardiac arrest. She was resuscitated but continued to deteriorate.
At 12.30pm her family was told her condition was not survivable.
Life support was switched off and she died at 1.55pm.