This story was on the 7.30 Report on ABC TV last night. Very sad and so tragic. Rather than the potential effects of epidurals I think this highlights bad practice and cover-ups. From what I could gather she was having a repeat (and so elective c/s). On TV it sounded like staff kept wanting her to be routine, and well she wasn't. Very, very sad. I also don't believe the notes were not done, they have in deed "gone missing". Perhaps and argument for having it all on computer, then some techy could find them.
marilyn ----- Original Message ----- From: "Andrea Robertson" <[EMAIL PROTECTED]> To: <[EMAIL PROTECTED]> Sent: Tuesday, March 09, 2004 6:54 AM Subject: [ozmidwifery] Disturbing report in the SMH > This article is in today's Sydney Morning Herald. There is no mention of > the reason for the caesarean, which would have been interesting. > > This kind of tragedy highlights the potential effects of epidurals and the > appalling "loss of the notes" that goes on. > ----------------------- > > > Misdiagnosis that led to mother's death 'defies belief' > > By Natasha Wallace > March 10, 2004 > > A woman died of an epidural abscess after doctors at Prince of Wales > Private Hospital and at two regional hospitals made hurried diagnoses and > then failed to take responsibility for her postnatal care, a coroner's > court was told yesterday. > > Handing down his findings into the death of Caroline Anderson, the deputy > state coroner, Carl Milovanovich, said it defied belief that she died after > an uneventful caesarean birth. > > Ms Anderson, 37, of Warren in central-western NSW, died on May 5, 2001, > less than a month after giving birth, when an epidural abscess burst, > spreading the infection to her brain and resulting in bacterial meningitis. > > Ms Anderson's husband, Evan Jones, has been left to care for their > children, Digby, now two, Basil, six, and Claudia, seven. > > Doctors at Prince of Wales Private, Warren District and Dubbo Base > hospitals failed to diagnose Ms Anderson's condition, despite her severe > leg and back pain, headaches and fever. > > Instead, she was misdiagnosed as having mechanical back pain, sacroiliitis, > mastitis, even an overdose of pain-killers. > > Of the three doctors who considered an epidural abscess, none ordered an > MRI scan, the only way to rule it out. > > Mr Milovanovich told Dubbo Coroner's Court: "Each of the doctors who > treated or saw Caroline was hasty in reaching a diagnosis and felt > comfortable with the notion that any major problem would be picked up by > someone else down the track. Not one doctor accepted a global > responsibility for Caroline." > > He said Ms Anderson's gynaecologist at Prince of Wales, Dr John Grey, was > responsible for her overall postnatal care and "should have realised that > something was seriously wrong". > > He has referred the matter to the Health Care Complaints Commission. > > A week after being discharged from Prince of Wales on April 17, Ms Anderson > was taken to Dubbo Base with severe back pain, but her admitting doctor, > Michael Ferres, forgot to see her, which Mr Milovanovich described as "a > major departure from accepted medical practice". > > A medical registrar, Patrick Groenstein, who diagnosed Ms Anderson with > sacroiliitis on April 26, was "the last medical practitioner who had an > opportunity to make decisions in regard to her diagnosis and treatment at a > time when appropriate medical intervention may well have saved her life", > Mr Milovanovich said. > > Dr Groenstein said he could not find her records at the time - his notes > have also since gone missing - and did not consult the emergency > specialist, Jamie Christie, who had ordered blood tests because he thought > Ms Anderson had a 30 per cent chance of having an abscess. > > Dr Christie did not record the diagnosis of an epidural abscess, which Mr > Milovanovich said was a "grave omission". He was disturbed by the "too > regular incident of notes, either taken or purportedly taken, being lost". > > Outside court yesterday, Mr Jones said his wife's death would be "a comedy > of errors if it wasn't so tragic". > > "The lack of record-keeping was a thread which ran through her entire > management," he said. > > Her anaesthetist at Prince of Wales, Dr Clive Collier, admitted at the > inquest to filling in her medical records four days after her death. > > Mr Jones said the Health Care Complaints Commission told him yesterday Ms > Anderson's case would be made a priority and an investigative team had been > established. > > A coronial investigator, Detective Sergeant Michael O'Rourke, said it was > "clear from the coroner's findings today that tragically Caroline Anderson > seems to have fallen through the cracks". > > Mr Jones has brought civil actions against the hospitals and doctors in the > Supreme Court. > > It remains unclear whether Ms Anderson contracted the golden staph bacteria > at Prince of Wales Private, although one expert told the inquest it was > "likely". > > ----------------------- > > > ----- > Andrea Robertson > Birth International * ACE Graphics * Associates in Childbirth Education > > e-mail: [EMAIL PROTECTED] > web: www.birthinternational.com > > > -- > This mailing list is sponsored by ACE Graphics. > Visit <http://www.acegraphics.com.au> to subscribe or unsubscribe. > -- This mailing list is sponsored by ACE Graphics. Visit <http://www.acegraphics.com.au> to subscribe or unsubscribe.
