A woman who died of sepsis three days after giving birth in western Sydney could have survived if her urinary tract infection (UTI) had been diagnosed, a coroner’s court has found.
It also found the woman, who was born in Vietnam, should have been offered interpreter services so she could communicate better with medical experts.
Gia Lam immigrated to Australia around 2010 and was 32 years old when she died on 4 February 2019 at Liverpool hospital.
Her uncle and aunt in Australia care for her son.
“All of the medical witnesses that saw Gia with her son in the hospital after his birth expressed that Gia was a dedicated and loving mother towards her son,” deputy state coroner Rebecca Hosking told the coroner’s court this week.
“It is devastating that she cannot be present for her son as it is clear she would have been a loving mother to him.”
Sign up for the Breaking News Australia emailThe inquest was asked to examine Lam’s prenatal and postnatal medical care at Fairfield hospital, as well as a home visit by a midwife – including the failure to use a Vietnamese interpreter during some interactions.
At an appointment at the hospital on 21 January 2019, Lam had difficulty passing urine – a “missed opportunity” to diagnose Lam with a UTI, “which, if appropriately treated, would have prevented her death”, Hosking found.
There was another missed opportunity to diagnose the UTI when Lam was admitted for induction of labour on 31 January. A registered interpreter was used.
Lam’s son was born through an instrumental vacuum-assisted delivery, during which she suffered a tear, which was sutured.
On 2 February Lam complained the area of the tear (the perineum) was sore, but was not found to be swollen when checked.
The obstetrics and gynaecology registrar who saw Lam later that morning was the last doctor to review Lam and made a plan for pain relief. Hosking’s report noted the doctor “did not have the benefit of an accredited interpreter”.
Lam told medical staff that she was in “a lot of pain” and was given a strong painkiller – however she complained of more pain on the morning of 3 February.
A midwife checked Lam’s perineum again and found no swelling. However a language barrier prevented her from sharing information on perineal care and afterbirth pain with Lam.
The midwife reported that she would hand over this information to the next shift so an interpreter could be organised, but “significantly, no registered interpreter was organised prior to [Lam’s] discharge”, Hosking’s report said.
No registered interpreter was organised in the postnatal period either, Hosking wrote.
At around 10pm, Lam appeared to be in “agony”, her husband said.
She was frequently urinating, and complained it was painful to do so.
Around midday the next day, 4 February, Lam phoned her friend Thi Thuy Trang Tran describing pain in her stomach and her desire to see a doctor.
When a midwife arrived at her home, Lam was “in a lot of pain”, “breathing quickly” and “appeared distressed”.
Lam phoned Tran to translate.
Tran advised the midwife that Lam was experiencing pain in her lower back that went to her stomach and had recently started feeling pain in her neck.
The midwife assessed her physically, “encouraged [Lam] to shower”, advised her to see her GP and to take paracetamol for the pain.
Hosking found the midwife should have acted on Lam’s deterioration and called an ambulance.
However, Hosking wrote that the expert evidence suggested Lam was already septic and “may have been too unwell for even appropriate treatment to alter the outcome”.
The midwife left with a plan to review Lam again the next day but by 5pm Tran found Lam lying in bed with fluid on the floor and an ambulance was called, the report stated.
She was taken to Liverpool hospital, where her heart rate began to drop. At 6.30pm she went into cardiac arrest.
The postmortem examination found Lam’s cause of death was sepsis due to “pyelonephritis of the right kidney due to acute and chronic cystitis”, which was consistent with the expert opinion that Lam was discharged from hospital with an undiagnosed UTI.
Hosking’s report stated that since Lam’s death “practices regarding interpreters has been strengthened” across the South Western Sydney Local Health District and Fairfield hospital specific guidelines.
“Interpreter use is now mandatory for women from culturally and linguistically diverse backgrounds when obtaining consent, during midwifery assessments, during discharge planning, and during all MSP visits.”
Sharon May, the director of nursing and midwifery services at Fairfield hospital, also gave evidence that since Lam’s death a new policy has been introduced to better detect abnormal symptoms, as well as revising escalation pathways.
Hosking noted Lam’s parents had died before the inquest without knowing the full circumstances of their daughter’s death.
Hosking conveyed her sympathy “to the Lam family and in particular, Gia’s son, her aunt and uncle … for the loss of their beautiful mother and niece”.
