Changes ... at Bathurst hospital since the "preventable" death of a woman who had just given birth should extend to all NSW hospitals, a coroner says.
... He was handing down the findings of his inquest into the death of Rebecca Murray, 29, who died after the caesarean ... of her healthy third child at Bathurst Base Hospital in June 2007.
She died of multi-system organ failure following postpartum haemorrhage ...
... the hospital failed to check her blood type and ensure it had adequate supplies before the caesarean.
... some supplies had to be sent from Orange Base Hospital - 55km away ...
"Had a full blood count ... and/or cross matching been done, Mrs Murray would have received blood transfusions at an earlier time and her death would have been prevented," ...
He also said the recovery room nurse had been inadequately trained.
Instead of immediately calling for help when Mrs Murray's blood pressure and pulse dramatically changed, she felt the priority was cleaning up the blood the patient was losing.
... the responsibility rested "squarely on the shoulders of hospital administrators" to ensure appropriately skilled staff were available for patients.
At the start of the inquest on June 1, NSW health authorities apologised to Mrs Murray's family, informing them that Bathurst Base Hospital now enforced the new blood count and supply policy.
But Milovanovich was told this practice had not been implemented across NSW.
"If the unexpected and avoidable death of a young mother at Bathurst justifies a change in policy at Bathurst Base Hospital, why should that policy not extend statewide," he said.
... "It is important that we take all steps to ensure the problems that occurred in this case will not be repeated as far as possible," he said.
It's great that they're acting on their mistakes, but what about the central issue: preventing preventable caesareans? This woman most likely had an avoidable caesarean. It was her third baby, and her baby was breech. Would a vaginal birth have been so risky for her? we know that rates of haemorrhage are higher for caesareans than for vaginal births.