MOTHER DIES AFTER A CHAIN OF BLUNDERS

Red News Readers,

This case illustrates graphically what can happen when managers in the health system try to run services and staffing levels on minimum cost. Those managers should read this story and cringe. This is what can happen when you put young inexperienced staff in positions where they are required to perform duties beyond their level of knowledge, skill and experience and without adequate clinical supervision. Minimum cost care can equal minimum quality care.

Jenny Haines

Mother dies after chain of blunders

Alexandra Smith, smh

March 6, 2008

REBECCA MURRAY was pregnant and healthy when she was admitted to Bathurst Hospital, but a day after delivering her third baby by caesarean the 29-year-old was dead. She had hemorrhaged, but nurses only realised when they saw her bloodied sheets.

Two weeks earlier, the 36-week-pregnant mother and her husband, Jim, had posed for this family photo with their son and daughter, Emelia and Lachlan, who were awaiting the arrival of a brother or sister. On June 24 last year, however, Mr Murray was in the waiting room of the old Bathurst Hospital, relieved that his newborn daughter, Grace, was healthy but unaware that down the corridor his young wife lay dying after a series of preventable errors.

A NSW Health incident report reveals that Mrs Murray had been transferred to a recovery ward after a routine caesarean when her blood pressure dropped dangerously low. Nurses should have called a medical emergency team but instead left her bleeding.

The report admits that the nurses were so inexperienced they did not know how to recognise a postpartum hemorrhage.

It was more than 30 minutes before hospital specialists arrived, and Mrs Murray was taken back to theatre for surgery. She needed a blood transfusion after losing huge amounts of blood, but the incident report concedes that two vital blood-warming machines were faulty. Both "kept turning off for no identifiable reason".

Worse still, theatre staff did not know how to use one machine and didn't know the password to operate it, the report said. Soon after, Mrs Murray suffered a cardiac arrest in theatre and doctors decided to transfer her to a metropolitan hospital. She was taken to the intensive care unit at Nepean Hospital. But, by 10.50am on June 25, she was dead.

The report concluded the "inadequate information exchange between treating clinicians contributed to a delay in recognition of the obstetric emergency" and "the rural base hospital medical records did not include an accurate record of blood loss, blood product and fluid replacement".

A new $98 million Bathurst Hospital opened in January, but surgeons suspended routine elective surgery last month, warning that serious design and construction flaws - such as an inadequate emergency alarm system and a pipe that leaked raw sewage into the maternity ward - were putting patients at risk.

Mrs Murray's death has been referred to the Health Care Complaints Commission and the coroner. But Mr Murray, left alone to raise three children, is demanding an apology from NSW Health and has not ruled out legal action. "This isn't a Third World country where a woman who is healthy goes in to have a baby and never walks out of those hospitals to kiss their kids goodnight again," Mr Murray told a news conference at State Parliament with the Opposition yesterday.

"My kids have to grow up having no mother. I believe she should still be alive if things had been done properly."

The Opposition health spokeswoman, Jillian Skinner, said it was a tragic example of systemic problems. "How is it that massive blood loss goes unattended in a NSW hospital?"

In Parliament, the Health Minister, Reba Meagher, said her sympathies were with Mr Murray.

But she said the Opposition could not attack the entire health system because of one tragic case.

"I am advised that Mrs Murray suffered acute complications following the birth of her child and was transferred to Nepean Hospital, when her condition continued to deteriorate after extensive treatment," Ms Meagher said. "While any maternal death is tragic, it is also extremely rare."

Whenever Mr Murray takes his children to visit their grandparents, he says, they think they are going to visit their mother - "asleep" in the hospital.