A busy emergency department doctor who diagnosed pregnant mother Annie O'Brien with gastro before her death from sepsis says she was feeling better and wanted to go home.
Five years after the death of Ms O'Brien and her baby girl at 18 weeks, a coroner has been urged to recommend systemic changes to private health system practices.
Ms O'Brien died on August 15, 2017, a day after going to Holmesglen Private Hospital with gastrointestinal symptoms.
Dr Hui Li Shi was the only doctor working in the full 10-bed department and took an hour to see Ms O'Brien - who was triaged to be seen within half that time.
She diagnosed Ms O'Brien with gastroenteritis, blamed on a chicken sandwich she ate for lunch before falling unwell with vomiting, diarrhoea and a fever that reached 40.3C.
She was treated with IV fluids and morphine for her pain before her membranes spontaneously ruptured. She was rushed to St Vincent's Private Hospital where her baby was stillborn.
Ms O'Brien died from multi-organ failure caused by sepsis at 1.55pm.
Dr Shi denied confirmation bias blinded her from considering another diagnosis after she determined Ms O'Brien had gastro.
After paracetamol and fluids she said Ms O'Brien's temperature dropped to 38.3C - still a fever, but less than earlier.
Her heart rate was lowering and her blood pressure increasing.
"Honestly at this stage I was still thinking my initial diagnosis (was correct)," she said.
"Later her condition changed because she was miscarrying. When her condition changed, I have an explanation for that."
She said when she checked on Ms O'Brien at about 9.30pm, an hour after her first review, the mother-of-one and lawyer reported feeling better.
She thought she might even manage to go home later in the evening, Dr Shi said, but was told she should remain overnight for more fluids and continued observations.
Ms O'Brien's father Brian Moylan, a retired GP, is representing the family at the inquest before State Coroner John Cain.
He questioned Dr Shi about her training to always consider the worst case scenario and why she hadn't done that with his daughter.
"From Annie's presentation, from first time I reviewed her, I didn't think she was really sick," the doctor replied.
