A doctor has agreed it was "careless" not to have got more information before ruling out antibiotics for a mother of four who died of septicaemia hours later.
... she had made the decision not to give broad spectrum antibiotics despite never having seen the 38-year-old or looking at her observation record.
Susannah, who had given birth to her first daughter a day earlier ... had been suffering stomach pains and a headache ... She was eventually misdiagnosed ... before dying from a bacterial infection ... which could have been treated with antibiotics.
[The] ... registrar ... told the inquest she had been told by midwives that Susannah's condition had been resolved when she decided against antibiotics.
She agreed she had not checked Susannah or her observation details when she made the decision.
... she had been unaware of Susannah's stomach pains, the fact she had been given 3 litres of intravenous fluids during the day and that she had also been given morphine. Dr Gibberd agreed with the suggestion by counsel assisting the coroner ... that it had been "careless" not to obtain more information about Susannah's condition.
Dr Gibberd also agreed with Coroner Alastair Hope that a "failure" had occurred in her not being notified by other staff of important symptoms including a drop in blood pressure.
... Dr Gibberd had also decided not to order a fresh sample of blood cultures after the laboratory detected the bottles used for the earlier sample had been past their expiry date.
She said she had believed that Susannah's condition had improved so there would be no need.
[The mdiwife] struggled to explain why there had been a gap of three hours where no staff had recorded Susannah's condition despite her being in severe pain ... the ward had been busy ...
I think that hits the nail on the head: when the health system is too busy to provide the necessary care to its patients, patients suffer. Unfortunately there's a world-wide shortage of midwives and in many hospitals midwives are replaced by nurses. Nurses are not qualified midwives and are therefore not qualified to care for pregnant, birthing and postnatal women.
Had this woman had continuity of midwifery care, or better still, her own private mdiwife, this most likely would not have occurred.