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Woman with splenectomy died postpartum of overwhelming infection (00HDC06473)

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(00HDC06473, 19 November 2002)

Midwife ~ House surgeon ~ Public hospital ~ Standard of postnatal maternity care ~ Response to infection ~ Guidelines for obstetric referral ~ Record-keeping ~ Rights 4(1), 4(2), 4(5), 6(1)(a), 6(1)(b)

A 28-year-old woman had hereditary spherocytosis, which was treated by a splenectomy when she was a child.

Patients with no spleen are vulnerable to unusually severe bacterial infections. The woman was healthy and well when discharged from midwifery care four weeks after the birth of her second child, but at about eight weeks postpartum she became unwell, rapidly deteriorated and died of pneumococcal septicaemia.

The question arose whether the midwives should have referred the woman for specialist care during her pregnancy.

The obstetric and midwifery advisors disagreed on this issue. The Commissioner accepted that the patient's condition did not strictly meet the criteria for referral in the relevant guidelines. Although it would have been prudent to refer her, given the rarity of her condition and the severity of the potential consequences of infection, the actions taken represented a reasonable standard of practice.

The midwives had had an informal discussion with an obstetrician, which fulfilled their obligation to consider referral, although standards are now higher and more formal discussion and records would be expected.

One issue was whether the midwives and house surgeon followed best practice in prescribing the antibiotic amoxycillin following the birth. An infectious diseases expert advised that this was appropriate to try to prevent infection, although it would have been ideal to initiate a daily prophylactic dose. It was held that they treated the patient with reasonable care and skill.

The patient's husband was concerned that his wife had not been given adequate warning about, and measures to prevent, postnatal infection. It was held that the patient was given the information that a reasonable patient in her circumstances would expect to receive.

The treatment given when the patient was admitted to hospital with an acute pneumococcal infection was appropriate. It is probable that by that time the infection was already too advanced for any treatment to save her life.

Very shortly after his wife had died, the patient's husband was asked whether he wanted a post-mortem to be carried out. The hospital apologised for the insensitivity of the request and advised that procedures had been changed. The hospital also lost the patient's medical records, which were subsequently found, but were incomplete. The hospital apologised and changed its record-keeping system. The case also contains comments on retrospective record-keeping by the midwives.



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