Coroner delivers finding into death of mother of undiagnosed sepsis

A coroner has handed down his findings into the death of a pregnant mother who died after she was incorrectly diagnosed by a private doctor.

The death of pregnant Melbourne mother Annie O’Brien could have been prevented if she was given antibiotics at the correct time by a doctor who also should have recognised the possibility of a fatal sepsis infection, an inquest has found.

Instead, Ms O’Brien, 37, only received antibiotics hours after she attended Holmesglen Private Hospital in Moorabbin in August 2017, and by the time of her admission to a second hospital after midnight, it was unlikely she could have been saved, State Coroner Judge John Cain said on Tuesday.

Mr Cain handed down his findings in the Coroners Court after a two-week inquest into Ms O’Brien’s death was heard in August last year.

Annie O’Brien’s death at age 37 could have been prevented if she was given antibiotics at the correct time, State Coroner John Cain said on Tuesday. Picture: Supplied

The inquest exposed a litany of failures regarding the Toorak lawyer’s treatment, who was 18 weeks’ pregnant when she attended Holmesglen on August 14 with a temperature of 40, severe back pains, diarrhoea and vomiting.

She was incorrectly diagnosed with gastro, having eaten a chicken salad with colleagues earlier that day, and after a rapid deterioration, died at St Vincent’s Private Hospital the next day following a miscarriage.

However, Mr Cain has decided against forwarding the conduct of Dr Hui Shi, who first treated Ms O’Brien at Holmesglen, or the conduct of her obstetrician Dr Vicki Nott, who treated her at St Vincent’s, onto the Australian Health Practitioner Regulation Agency, despite the wishes of Ms O’Brien’s father, Dr Brian Moylan.

Mr Cain said Dr Shi, who first saw Ms O’Brien at about 8:30pm on August 14, should have given her antibiotics and considered the possibility of sepsis when her condition deteriorated for a second time at 10:15pm.

Dr Brian Moylan, the father of Annie O’Brien, outside the Coroners Court of Victoria in August last year. Picture: NCA NewsWire / Luis Enrique Ascui

At 11:30pm, when Ms O’Brien’s membrane ruptured, Dr Shi should have reviewed Ms O’Brien’s diagnosis again and broad-spectrum antibiotics should have been administered, Mr Cain found.

He said while Ms O’Brien had her greatest chance of survival if they were administered at 8:30pm, it was still more likely than not she would have survived if she’d received them at 10:15pm or 11:30pm.

Mr Cain said there was an “unacceptable” miscommunication between Dr Shi and Dr Nott when it was agreed that, following to her membrane rupture, Ms O’Brien would be transferred to St Vincent’s and to Dr Nott.

Dr Shi said she had impressed on Dr Nott the severity of Ms O’Brien’s condition in her two phone calls prior to the transfer, while Dr Nott insisted she had “no appreciation” of how sick the patient was.

Annie O’Brien died in St Vincent’s Private Hospital on the afternoon of August 15, 2017 after a doctor failed to pick up on her condition of sepsis at another hospital, a coroner found. Picture: NCA NewsWire / David Crosling

Ms O’Brien arrived at St Vincent’s at 12:15am and appeared “very distressed,” according to the evidence of a midwife, while Dr Nott first got to her bedside at 1:30am, when she became convinced of the presence of sepsis due to her “altered state of mind”.

The first dose of antibiotics wasn’t delivered until 2:46am, more than three hours after Ms O’Brien’s membrane had ruptured, and she died shortly before 2pm that afternoon.

Mr Cain’s recommendations included for specific advice on maternal sepsis to be provided in the Safer Care’s “Think Sepsis, Act Fast” guidelines, and for Safer Care to develop statewide tools assisting in the proper delivery of handover notes.