A mother died after giving birth to twins at Calvary Hospital in Canberra because her obstetrician failed to deliver adequate care, the ACT coroner has found.
Corinna Anne Medway, 33, had suffered pre-eclampsia, also called pregnancy induced hypertension, during her pregnancy with twin girls in 2011.
After the birth, Ms Medway complained of serious chest and back pain and was prescribed 10mgs of morphine by her doctor Andrew Foote.
But the coroner Margaret Hunter told the court she had no relief and quickly became seriously ill.
"Her partner Ben Ryan came out to tell [an attending doctor] that Ms Medway was very drowsy and could not move her arm," she said.
A scan performed indicated a "significant haemorrhage in her brain".
The coroner found she died of a cerebral haemorrhage brought on by escalating blood pressure.
Ms Hunter said Dr Foote had been aware of Ms Medway's "critical" blood pressure readings at 6:00pm the night before her death, and that he had failed to deliver adequate care.
"It is my view, and I am satisfied to the requisite standard, that Dr Foote failed to administer appropriate treatment for the acute pregnancy induced hypertension suffered by Ms Medway," she said.
"18:00 hours was a critical time and treatment should have been instigated immediately.
"Further, I am satisfied that treatment was available within a reasonable period of time, sufficient to have ameliorated the significantly high blood pressure."
Ms Hunter recommended that nursing staff, midwives, GPs and specialist obstetricians undertake specific training on the risks of pregnancy-induced hypertension.
She also recommended that practitioners provide literature on the condition to pregnant women in their care.
