Hospitals should be forced to ensure they have adequate supplies of blood for every woman about to give birth by caesarean, a NSW coroner has recommended.
Rebecca Murray died from multiple-organ failure after delivering a healthy baby girl by emergency caesarean at Bathurst Base Hospital in June 2007.
She suffered a severe postpartum hemorrhage, a medical event that is generally treatable, but the recovery nurse was not trained to monitor its aftermath and the hospital wasted valuable time checking her blood type before a transfusion could be administered.
Some of the blood had then to be brought from Orange Base Hospital.
The Deputy State Coroner, Carl Milovanovich, who conducted an inquest into Ms Murray's death, yesterday found that it could have been prevented if her blood count and type had been checked before the operation and the staff were better trained.
Do we have to wait for another mother to die in similar circumstances before there is some change?
He recommended the Health Minister implement a policy that requires all hospitals to check the blood count, group and supplies for all elective and emergency caesareans.
Bathurst hospital has responded to Mrs Murray's death by creating such a policy, but Mr Milovanovich said it was clear many regional hospitals had not followed suit.
"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.
"Do we have to wait for another mother to die in similar circumstances before there is some change?"
Mr Milovanovich also criticised hospital administrators for not ensuring their staff were appropriately skilled.
Doctors did not verbally advise the recovery nurse that Ms Murray's wound had torn after her caesarean and that she had suffered a severe postpartum hemorrhage, and the nurse did not read the operation report.
When Mrs Murray started showing symptoms that should have alarmed the nurse, she was inadequately trained to recognise the gravity of the situation.
It was only when a more experienced nurse "popped in" to check on Ms Murray that emergency action was taken.
"The responsibility of ensuring appropriately skilled staff are available to deal with patient care must - rest squarely on the shoulders of hospital administrators," Mr Milovanovich said.
Mrs Murray's husband, Jim, said outside Westmead Coroner's Court that he did not blame the individual nurse, but wanted to see systemic changes.
"I'm angry that they did that to the nurse, put her in a position where she didn't know what she was doing," he said.
Mr Murray remembered telling his wife he loved her in her last lucid moments and was pleased that she got to meet their youngest child before dying. "She touched her cheek, and that was it," he said.
"At least she got to touch her."
The Health Minister, John Della Bosca, offered his sympathy to Mrs Murray's family and said he would consider the recommendations.
Discuss birth issues with Essential Baby members.