A doctor who examined a pregnant Melbourne mother hours before her death from sepsis has apologised after mistakenly diagnosing her with gastroenteritis, as the woman's family urge the coroner to be "courageous" in his investigation.
Annie O'Brien died on August 15, 2017 from multiple organ failure caused by septicaemia and streptococcal A.
The 37-year-old mother of one was 18 weeks pregnant when she began suffering persistent vomiting, diarrhoea and back pain.
She went to the Holmesglen Private Hospital's emergency department, where she recorded a temperature of 40 degrees Celsius and was diagnosed with gastroenteritis.
When Mrs O'Brien's waters broke, she was transferred to St Vincent's Private Hospital where she died several hours after a stillbirth.
In the years that followed, her parents — retired GP Brian Moylan and former nurse Marguerite — have been pursuing answers from Holmesglen, St Vincent's and Victorian health authorities about what went wrong with their daughter's diagnosis and treatment.
On the fifth anniversary of Mrs O'Brien's death, state coroner John Cain opened a two-week inquest by acknowledging the date.
"I am sure you don't want to spend it here," Judge Cain told Mrs O'Brien's family.
"I overlooked it in listing this matter. I am acutely aware of the distress this may cause.
"The passage of time has not diminished your grief. I understand it is severe and ongoing."
Judge Cain told the court the proceedings were not about assigning guilt or blame for Mrs O'Brien's death but to prevent similar adverse events.
Dr Moylan was the first witness to give evidence and is also taking part in the questioning of witnesses by representing himself at the hearing.
He told the court he believed his daughter's death was avoidable and many parties had tried to frustrate their investigations by saying they would not comment while the matter was before the coroner.
He named the heads of Healthscope, Holmesglen Private Hospital and St Vincent's Private Hospital, as well as the health minister at the time of his daughter's death, Jenny Mikakos, and Premier Daniel Andrews.
"A grieving family deserves full information on adverse events relating to their loved ones," he said.
"We shouldn't be burdened with the task of investigating Annie's death.
"I challenge the court to be courageous and forensic in the pursuit of answers."
In a statement submitted to the coroner, Dr Moylan said the family wanted Mrs O'Brien's death to be the catalyst for systematic changes for sepsis management, as well as accountability and transparency during independent investigations into critical events in private hospitals in Victoria.
"It could have been any one of us in the bed that night but sadly, it was our daughter," he said.
"It haunts us how frightened and devastated Annie would have felt when her clinician said 'her body is shutting down' following her delivery."
The inquest will consider a range of issues including whether doctors should have considered a sepsis diagnosis given Mrs O'Brien's fever, heart rate and back pain, the time it took to administer antibiotics, communication between Mrs O'Brien's ED doctor, obstetrician and midwives at St Vincent's, as well as the ability of Safer Care Victoria to conduct reviews into private hospitals.
Outside court, the Moylans said the private hospital system failed their daughter.
"We wouldn't recommend going to a private hospital emergency department unless it's accredited by the Australian College of Emergency Medicine," said mother, Marguerite Moylan.
"We think there needs to be a full inquiry because we found so many significant failures across the board."
Symptoms consistent with gastro, ER doctor said
Emergency medicine physician Hui Shi told the court she was the only doctor in the Holmesglen emergency department when Mrs O'Brien was admitted and there was no gynaecologist or obstetrician rostered on at night.
Dr Shi said all 10 emergency department beds were occupied and Mrs O'Brien was triaged as a category three patient, meaning she should have seen her within 30 minutes.
She told the court she was comfortable with the one-hour time frame it took to see Mrs O'Brien, based on her symptoms.
"There were two other patients before her and they were very sick," Dr Shi said.
The court was told Mrs O'Brien was diagnosed with gastroenteritis based on her symptoms of vomiting and diarrhoea.
Dr Shi acknowledged that back pain was not usual with gastroenteritis but she thought it could have been related to Mrs O'Brien's physical position when she was vomiting and experiencing diarrhoea.
In a statement to the court, Dr Shi said she did consider sepsis but "her presentation and quick improvement with our simple management was against the diagnosis".
Dr Shi told the court an ultrasound noted a good fetal heart rate.
While arranging for Mrs O'Brien to be admitted to a ward, Dr Shi observed her moaning in pain and that she had developed minor abdominal pain, causing her to consider whether Mrs O'Brien was in the early stages of a miscarriage.
Dr Shi said she spoke to Mrs O'Brien's obstetrician, Vicki Nott, and was told the baby would not survive, so a transfer to a maternity hospital was not needed.
But she said as soon as Mrs O'Brien started bleeding, she called for an urgent ambulance to take her to St Vincent's Private Hospital, which arrived within five minutes.
Under further questioning, Dr Shi told the inquest there was no diagnostic tool to predict if a patient would develop sepsis.
"So you have to make a clinical judgement as a clinician. So I made that judgement at the time, unfortunately. I am sorry," she said.
Private hospitals not compelled to provide information to investigators
Megan Goadby, acting director of the Centre of Patient Safety and Experience at Safer Care Victoria (SCV), told the court Holmesglen and St Vincent's hospitals did not notify SCV about Mrs O'Brien's death.
She told the court SCV's statutory powers differed in relation to public and private hospitals.
She said SCV did not have the power to force private hospitals to provide information about incidents like Mrs O'Brien's death if they did not receive state government funding.
She said under recently amended legislation which takes effect later this year, private hospitals will need to notify a patient if they suffer significant injury because of the conduct of the hospital, but they only have to provide a report if it is requested by SCV.
Holmesglen Private Hospital, the Holmesglen emergency department and St Vincent's Private Hospital are represented at the hearing and passed on their condolences to the family.
The inquest continues.
