The New South Wales deputy state coroner has found that a woman who died six days after a Caesarean-section birth received “grossly inadequate” medical care.
Michaela Perrin gave birth to a healthy baby girl in the Lismore Base Hospital, on the New South Wales north coast, in October of 2014.
She was discharged three days after the caesarean-section delivery, but developed wound pain and returned to the hospital a day later.
The 26-year-old was sent home with pain killers, but admitted the following day.
She died of sepsis six days after the birth.
Lack of awareness
The deputy state coroner Magistrate Harriet Grahame found Ms Perrin would have survived with appropriate care, but the doctor who treated her had a wholly inadequate knowledge of the condition.
“Throughout her evidence Dr [Cristina] Penaneuva showed a startling lack of awareness in how to recognise sepsis and how serious the condition is,” Ms Grahame said.
“The issues identified with Dr Penaneuva’s clinical practice were not limited to a single mistake.
“Any practitioner can make an error of judgement, especially when busy, we are all imperfect and capable of human error.
“Dr Penanueva’s failings were of a different magnitude.
“They included a serious lack of essential medical knowledge, inadequate medical note taking and clinical handover, and an inadequate approach to history taking and the physical examination of a patient.
“Unfortunately when confronted with these issues, Dr Penaneuva demonstrated a tendency to try and shift the blame onto others.”
Condition now deemed rare
The NSW Health website lists maternal sepsis as a severe bacterial infection, usually of the uterus, which can occur in pregnant women or more commonly, in the days following childbirth.
It says the infection was once a common cause of maternal death, but [that] is now rare due to improved hygiene standards and effective antibiotics.
Doctor’s conduct to be investigated
The coroner has recommended the Health Care Complaints Commission investigate the doctor’s conduct, and the case be used to educate midwives and other staff at the Lismore Base Hospital.
She said her recommendations were limited only because the changes already made at the Lismore Base Hospital demonstrated a willingness to learn from the tragedy, not because there were no significant problems in the care it offered.
It was noted that while Dr Penaneuva remained a medical practitioner, she was no longer working in an obstetrics and gynaecology role at Lismore Base Hospital.
The findings have been welcomed by Ms Perrin’s mother, Cathy Perrin.
“I think [my reaction] is one of relief,” Cathy Perrin said.
“I know the Northern Rivers Local Health Network has already started putting in lots of changes [so] you have to be thinking ‘good my daughter hasn’t died in vain’.”
Health district accepts findings
Northern NSW Local Health District chief executive Wayne Jones said the district acknowledged the findings of the coroner and accepted the care provided to Ms Perrin did not meet the standard it wished and expected in its hospitals today.
“As the coroner noted, we have made significant improvements in patient care in the last couple of years,” he said.
“Dr Penanueva had been working with us for a number of years and had performance reviews in accordance with her performance program, and did not identify the lack of skill and expertise as identified through the coroner.
“In fact there’d been no major issues with her care prior to this incident.”