Opinion
Maternal death – a preventable tragedy
27th Oct 2022
Childbirth in Australia today is not routinely associated with the risk of maternal death. In fact, our maternal mortality rate ranges from 5.0 to 8.4 per 100,000 women giving birth.[i] Yet this was the situation a healthy 32-year-old woman faced just three days after giving birth to her first baby. This mother delivered her baby in a large teaching hospital, and was under the care of the midwifery team with other medical staff available if required.
From my perusal of the documented clinical notes, the midwifery staff had commented on the mother’s offensive smelling vaginal loss only a few hours after her delivery. They incorrectly assumed it was due to a lack of hygiene and encouraged her to shower more frequently. The midwives caring for her did not instigate any investigation of this unusual situation. They failed to accurately monitor her condition and they failed to recognise her acute deterioration and the serious potential implications of the situation.
The first clinical error
The midwives should have notified the medical team of the abnormality. They should have taken swabs for culture and they should have increased their clinical observations of the young mother. Had this infection been detected early, a course of antibiotics would have been prescribed by the medical team, and the mother would be alive today. This was the first clinical error by the midwives, which set in motion the catastrophic chain of events that ultimately led to the young mother’s death in the Emergency Department (ED) three days later.
The documentation shows that the mother’s condition kept deteriorating and she kept complaining of increasing pain, increasing foul-smelling discharge, and a generalised feeling of malaise and fatigue. Still the staff failed to recognise her acute clinical deterioration and did not escalate her care; they merely kept advising her to shower more frequently.
The second clinical error
The second clinical error by the midwifery staff occurred when they discharged the mother from hospital with her baby on day two, post delivery. The failure to meet set discharge criteria according to hospital procedures and protocols was overlooked or ignored and, despite increasing and undiagnosed symptoms of sepsis, the mother was sent home. Her husband reported that she kept complaining of increasing pain in her legs, arms and neck, and that she was unable to care for their baby. The family had little English and during her stay in hospital no interpreter was offered or called to assist at any time.
The third clinical error
The third clinical error occurred when one of the midwives visited the mother at home on the afternoon of her discharge. The mother again complained of increasing severe pain, however, the midwife merely advised the mother to take Panadol and to book in to see her GP when she could. The midwife did not take any clinical observations of the mother. The midwife then left the home. She failed to recognise the signs of acute clinical deterioration, to escalate the level of care, call an ambulance or offer any kind of appropriate clinical assistance.
The next morning the mother’s condition was so critical that her husband called an ambulance, as she was losing consciousness. By the time the ambulance arrived, the young mother was critically unwell due to raging septicaemia or puerperal fever (child bed fever). Although the ED team worked tirelessly on this young mother, the sepsis or gross infection overwhelmed her entire system.
The mother died alone without her family, on a trolley in ED at the same hospital where only three days earlier she had delivered her first baby.
The fourth clinical error
The fourth clinical error occurred the day after the mother died. The same midwife who had visited the home the day before arrived at the house, rang the bell and – smiling – announced to the grieving husband that she was there to check on the mother and the baby. The husband informed the midwife that his wife had died the day before, and the midwife quickly left the home. This final insult to this poor family was unforgivable. The lack of communication between the hospital staff was absolutely appalling.
A clinical midwife’s point of view
The Coroner requested me to prepare a report on this maternal death, from a clinical midwife’s point of view. Although a coronial medical examiner conducted the post-mortem to determine the clinical cause of death, the report for the Coroner as to the contributing and causative factors, the usual clinical practice of competent midwives, and potential deviation from the National Safety and Quality Health Service (NSQHS) Standards, needed to be prepared. Expert nurse/midwife witnesses have the clinical expertise, vast experience, deep knowledge of policies and procedures, and clear understanding of the NSQHS Standards to assess and comment upon another nurse’s and midwife’s performance, clinical skills and care provided to their patients.
As a nurse with over 40 years of experience in both the operating theatre and midwifery, I have seen and been involved in my share of tragic situations, however, in this case, the enormity of the clinical errors leading to the tragic loss of a young mother cannot be understated, or the loss diminished by time. As deeply as I feel for this family, no words of mine will give this baby her mother back or comfort her husband. The role of the expert witness midwife in cases such as these is invaluable. My role was to examine the facts of the case, and investigate where the nursing care provided failed to protect this young mother from harm. Ultimately, my fervent hope is that my report, along with the Coroner’s findings and subsequent recommendations, will initiate changes in the training and education of all midwives (but of the midwives involved in this event in particular), and that this situation never occurs again. As all nurses must carry personal indemnity insurance, this tragic story is now playing out in the civil litigation arena.
The ALA thanks Denise Donaldson for this contribution.
Denise Donaldson has over 45 years of experience as an operating theatre nurse, nursing educator, university tutor and lecturer.
The views and opinions expressed in this article are the authors’ and do not necessarily represent the views and opinions of the Australian Lawyers Alliance (ALA).
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[i] Australian Institute of Health and Welfare, Australia’s mothers and babies: Maternal deaths (Dec 2020)
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