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17 Dec

Medical fail in Victorian pregnancy death

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Elizabeth Gorman died a day after being discharged with painkillers from the Royal Women’s Hospital.A coroner has recommended changes to the triage systems at key Melbourne hospitals after a pregnant woman died from clots in her lungs, despite being earlier discharged with painkillers.
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Elizabeth Gorman, 35, died in her first trimester of pregnancy the day after being discharged from the Royal Women’s Hospital in September 2012.

She attended the Northern Hospital at Epping on September 2 that year with severe morning sickness and was discharged after receiving intravenous fluids.

Ms Gorman attended the emergency department of the Royal Women’s Hospital the next day with rib pain and was sent home after being treated with oxycodone.

The resident medical officer, a junior, believed she had musculoskeletal pain from her previous heavy vomiting and did not order an electrocardiogram.

On September 4, Ms Gorman was returned to the emergency ward in an ambulance with an altered heart rate, low blood pressure, chest pain, shortness of breath, and was in an altered conscious state.

While being assessed, Ms Gorman suffered a cardiac arrest.

She was transferred to the Royal Melbourne Hospital and underwent surgery for clots in her lungs but died a few hours later.

It was determined Ms Gorman’s lung clots had formed following the development of early pregnancy deep vein thrombosis.

In his inquest finding, delivered on Thursday, coroner Peter White said the resident medical officer did not explore Ms Gorman’s condition sufficiently and wasn’t sufficiently trained or experienced to understand whether she needed to take advice from senior staff.

He said the responsibility for those failures lay with the Royal Women’s Hospital.

Mr White added Ms Gorman should have been taken by ambulance to the Royal Melbourne Hospital, not the Royal Women’s Hospital.

He recommended the three organisations meet to consider a single triage point at Royal Melbourne Hospital.

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