It was immediately clear to a midwife that Annie O'Brien had more than gastro when the pregnant mum was rushed from one Melbourne hospital to another.
The lawyer and mother-of-one had taken herself to Holmesglen Private Hospital's emergency department with severe gastro symptoms on August 14, 2017.
At 2.12am the next day she delivered her baby stillborn at 18 weeks. Ms O'Brien's life support was turned off at 1.55pm after sepsis led to multi-organ failure.
Her family has called on Victoria's State Coroner John Cain to make recommendations for systemic changes to private hospitals, believing her death was preventable.
Holmesglen's sole emergency department doctor Hui Li Shi diagnosed Ms O'Brien with gastroenteritis and was treating her with paracetamol and fluids.
She started feeling unwell after a chicken sandwich and Dr Shi told an inquest into her death that she didn't consider sepsis because Ms O'Brien's presentation fitted the gastro diagnosis.
When her membranes spontaneously ruptured, she was urgently transferred to St Vincent's Private Hospital where Gillian Codd was the midwife in charge.
"She was not critical, but very unwell," she said of the 37-year-old's condition on arrival.
"It certainly looked more than gastro. That was our concern, this no longer looked like gastro or food poisoning."
She was distressed and her temperature was 39C - down from its earlier peak at 40.3C.
Ms Codd told an inquest into Ms O'Brien's death that she advised her obstetrician Vicki Nott that she was seriously worried - a technical term - about her patient's condition.
"With ruptured membranes and a temperature of 39 it's a fairly significant infection," she said.
"I've never seen anyone with a temperature of 39C with just gastroenteritis."
In a statement Ms Codd said Ms O'Brien hadn't left her thoughts since that night and offered her condolences to her family.
She said she believed the team did everything possible and the best they could given the circumstances.
St Vincent's Private Hospital now has a maternal sepsis kit in delivery rooms, including a copy of the hospital's sepsis guidelines.
Staff are trained annually and the kits are checked daily for their presence and a more detailed check that everything is within date is conducted monthly, she said.
