ACT: Pregnant woman's death in hospital 'avoidable': coroner

AAP General News (Australia)
08-08-2008
ACT: Pregnant woman's death in hospital 'avoidable': coroner

By Julian Drape

CANBERRA, Aug 8 AAP - The death in a Canberra hospital of a 50-year-old woman heavily
pregnant with twins was avoidable, although no one person was criminally responsible,
an ACT coroner has found.

But the woman's husband is pressing ahead with plans to sue the John James Memorial
Hospital over the incident six years ago.

Nancy Aun, a radiologist, died following a sudden haemorrhage 11 days after being admitted
to the hospital in 2002.

She was 34 weeks pregnant with IVF twins.

Dr Aun was found by a kitchen maid on the floor of her room about 6.50am on July 29.

She had previously been checked at 4am.

The room was dark and there was blood on the bed, floor, curtains and wall.

An emergency specialist told the coroner there was at least one hour, and probably
two, between Dr Aun's "placental abruption" and her being found on the floor.

Experts said if Dr Aun had been discovered earlier it would have been "far less likely"

she would have died.

The coronial inquest examined why there had been a delay and why Dr Aun hadn't called
for help with her bedside buzzer.

Chief coroner Ron Cahill today said it was "impossible to determine the particular
reason why the alarm system was not activated" but "the tragic death of Nancy Aun may
have been avoidable".

However his investigations revealed no criminal offences.

One call buzzer to alert nurses was mounted on Dr Aun's bedside table while another
was connected to a flexible cord.

Both worked but it was suggested the expectant mother either couldn't see the buttons,
couldn't reach them or was "so overcome by pain to be unable to activate them".

Mr Cahill recommended all obstetric hospitals should ensure adequate lighting at all
times for patients to access the alarm system.

He said they should ensure the bedside button was within "comfortable reach" and the
cord button be within reach "at all times ... preferably fixed on the bedding or bed".

The coroner also recommended hospitals implement guidelines for the management of high-risk
obstetric patients, including regular patient observations.

Dr Aun's husband, Colin Gilmore, a consultant anaesthetist, is suing the hospital over
his wife's death.

A civil claim was filed in the ACT Supreme Court earlier this year.

An emotional Dr Gilmore said today's recommendations would go a long way to improving
standards of care.

"I feel very confident if and when these recommendations are instituted it will significantly
improve the standards offered to expectant mums and their babies at all obstetric hospitals,"

Dr Gilmore told reporters outside the ACT Coroners Court.

Tomorrow will be the sixth anniversary of his wife and twins' funeral, he said.

AAP jcd/rl/cjh/mn

KEYWORD: AUN

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