The parents of a pregnant woman who died from septicaemia hours after being misdiagnosed with gastroenteritis say her death was preventable.
The Victorian coroner has released the findings of an inquest into the death of Annie O'Brien, who died in 2017 shortly after miscarrying her baby at 18 weeks gestation.
The 37-year-old went to the emergency department (ED) at Holmesglen Private Hospital in Moorabbin on August 14, 2017, with persistent vomiting, diarrhoea and back pain.
She told ED staff she had been feeling unwell since eating a chicken salad at lunch.
She recorded a temperature of 40 degrees Celsius and was diagnosed with gastroenteritis.
When Ms O'Brien's waters broke, she was transferred to St Vincent's Private Hospital, where she was given antibiotics in the early hours of the morning of August 15. She later died, several hours after a stillbirth.
State coroner John Cain found the cause of death was septicaemia during pregnancy, secondary to a genital tract infection.
Ms O'Brien was represented at the inquest by her parents, Brian and Marguerite Moylan.
Mr Moylan described his daughter's care as "dreadful" and said she had a right to expect more.
"In our view, her death was preventable," Mr Moylan told reporters outside the Coroners Court of Victoria.
"With reasonable systems of care, with reasonable clinical judgement she would be alive today, her baby would be alive today," he said.
Coroner identifies 'miscommunication' and other deficiencies in care
The inquest considered a range of issues, including the ability of Safer Care Victoria to conduct reviews of private hospitals, whether doctors should have considered a sepsis diagnosis given Ms O'Brien's fever, heart rate and back pain, the time it took to administer antibiotics, and the communication between Ms O'Brien's ED doctor, obstetrician and midwives at St Vincent's.
Judge Cain said medical experts called on during the inquest gave varying opinions on Ms O'Brien's chances of survival had she been given antibiotics earlier in her treatment.
He found her best chance of survival would have been if she was given antibiotics by 8:30pm at Holmesglen Hospital.
He said by the time Ms O'Brien arrived at St Vincent's, she could not be saved.
"I am satisfied that by the time she arrived, her clinical condition was so serious there was no medical or nursing management that could be taken that would prevent her death," he said.
The coroner did not make any findings about the nursing or medical management Ms O'Brien received at either hospital, but said there were deficiencies in her care and several issues which warranted comment.
Hui Li Shi was the ED doctor who treated Ms O'Brien at Holmesglen Private Hospital when she arrived on the evening of August 14.
The coroner found Dr Shi's initial diagnosis of gastroenteritis was reasonable and said by 9:30pm, Ms O'Brien reported feeling much better and considered going home.
However, the coroner said Dr Shi should have considered other options when Ms O'Brien later started complaining of severe back pain, for which she was given morphine.
"Dr Shi should have known gastroenteritis was not likely and by the time her condition changed should have prescribed antibiotics," Judge Cain said.
When Ms O'Brien's membranes ruptured at 11:30pm, Dr Shi believed her temperature of 40.3C was causing a miscarriage and organised an emergency transfer to St Vincent's hospital.
Dr Shi made two calls to the pregnant woman's obstetrician, Vicki Nott, who agreed to meet her patient at St Vincent's.
The coroner said there were issues around communication between the two doctors, who later disagreed about what happened on the night.
Dr Shi said she told Dr Nott about the urgency of the transfer, but Dr Nott said she did not know it was a medical emergency and did not arrive until an hour after Ms O'Brien.
"Two experienced doctors should be able to communicate effectively," Judge Cain said.
"Miscommunication such as this simply should not happen."
Blood test results that would have shown sepsis could not be processed at Holmesglen, as the pathology department was closed.
They were transferred to another facility overnight and by the time they were returned Ms O'Brien was dead. However, this was not covered in the scope of the inquest.
"We're disappointed in the transfer of the bloods," Ms Moylan said outside court.
"We know that the pathology closed at the hospital at 5pm."
Parents promise to fight to 'make the system safer'
The coroner's recommendations included that the Victorian Department of Health mandate that all public and private health facilities undertake root-cause analysis reports of so-called sentinel events and serious adverse patient safety events.
He also recommended that Safer Care Victoria (SCV) give consideration to amending the "Think Sepsis Act Fast" guideline to include a section on the treatment of sepsis in pregnant women, including information about recommended antibiotics that should be administered.
He also said SCV should develop and promote tools to assist in the proper handover of patients between health professionals and in transfers between health services.
He said the procedure for addressing potential sepsis should be displayed in prominent places and there should be comprehensive communication of their existence.
"It is troubling to me that there does not appear to have been any formal education or training (in adult sepsis pathways) at Holmesglen Hospital," he said.
Mr Moylan said he was pleased there had been an inquest into his daughter's death and now wanted a public inquiry into the health system.
"Adverse events like this tend to be settled in a legal manner that is confidential settlements with non-disclosure agreements," he said.
"The public isn't hearing about these adverse events and nothing changes, nothing gets fixed."
Ms Moylan said sepsis education was key to preventing similar deaths occurring.
"If Annie knew to say to anyone that night, 'Could this be sepsis?' she may be alive today and her baby," Ms Moylan said.
"Annie is driving us, it's not us, it's our beautiful daughter who is no longer here and doesn't have a voice," she said.
"I promise all Victorians that we will do what we can to make the system safer."