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The death of a young Victorian woman while giving birth to her son was "tragic and unexpected" and could have been prevented, a coroner has found.
Key points:
- Sommer Warren was heavily pregnant when she died in 2014 after being induced at Goulburn Valley Health
- The coroner found doctors had failed to administer hypertension treatment at an appropriate time
- She apologised to Ms Warren's family for the time taken to finalise the coronial process
Sommer Warren died on a hospital bed at Goulburn Valley Health in Shepparton on October 6, 2014.
The 18-year-old suffered severe hypertension and a seizure after being induced at the hospital.
Releasing her findings, Coroner Audrey Jamieson said there had been a failure to administer blood-pressure and anticonvulsant treatment to Ms Warren, and that it posed a missed opportunity in preventing her death.
"Sommer's death was unexpected and tragic, and the tragedy is compounded by her very young age," Ms Jamieson said.
"I offer my sincere condolences to her family and friends."
Pregnancy classified as high-risk
Ms Warren had been turned away from the hospital six times in the weeks before her death.
By the time she was admitted to the facility, she was in the late stages of pregnancy (41 weeks) and on the red pathway for birth patients, meaning her pregnancy was classified as high-risk and required specialist care.
Ms Warren's mother, Leisa Scammell, told an earlier inquest hearing that she'd watched on helplessly as her daughter's condition deteriorated throughout the day, saying she felt like she had been abandoned by hospital staff.
"It shouldn't happen in this day and age. It shouldn't happen," Ms Scammell said.
"It was meant to be the happiest day of her life and mine."
Doctors 'failed to administer treatment early enough'
The inquest heard Ms Warren slipped in and out of consciousness throughout the day, becoming increasingly drowsy and flickering her eyelids.
Ms Jamieson said doctors should not have put this down to maternal exhaustion.
She said they had failed to administer intravenous labetalol and magnesium sulphate at an appropriate time.
"These medications should have been administered at the time that Sommer had a dropping conscious state," she said.
"Had her hypertension been treated, Sommer's generalised seizure would have, more likely than not, been prevented.
"Consequently, her death would have been prevented."
Ms Jamieson accepted the coronial panel's suggestion that the doctors' failure to provide the treatment was below the acceptable standard of care.
The panel also had concerns about a three-minute delay in applying CPR after Ms Warren entered cardiac arrest.
She was also administered 50 milligrams of antihypertensive medication after the onset of cardiac arrest, however the panel agreed 20 milligrams was the accepted starting dose.
The findings have been referred to obstetrics authority the Society of Obstetric Medicine in Australia and New Zealand.
Coroner 'satisfied' with changes made
Ms Jamieson said she was satisfied Goulburn Valley Health had made preventative changes following the death.
She said there were no shortcomings in Ms Warren's management by the hospital until the day of her death and made no specific recommendations to GV Health.
"I'm satisfied the hospital has identified and made appropriate changes with the aim of promoting health and safety and preventing like deaths."
Ms Jamieson apologised to Ms Warren's family for the time taken to finalise the coronial process and admitted the court failed to communicate with her family.
Ms Warren's family and GV Health were contacted for comment.
Topics: courts-and-trials, womens-health, pregnancy-and-childbirth, maternal-and-child-health, law-crime-and-justice, healthcare-clinic, healthcare-facilities, regional, people, human-interest, shepparton-3630
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