Attempts to resuscitate Wanganui woman Tonia Newton during complications in childbirth were "reasonable and appropriate in the circumstances" - but did not come quickly enough.
That was one of the conclusions of coroner Tim Scott, in the Coroner's Court at Palmerston North, yesterday when he concluded a four-day inquest into the death of Mrs Newton. Mrs Newton died, aged 37, from an amniotic fluid embolism, which occurred as she was giving birth to her fourth child on October 6, 2008, at Wanganui Hospital.
Her baby, a boy, survived.
Mrs Newton complained she felt sick and was unable to push any more. She collapsed and began turning blue.
The crisis that unfolded over the next approximately 13 minutes was witnessed by a number of Mrs Newton's family and friends. They questioned the adequacy of efforts to resuscitate her, and why intubation, considered the "gold standard" of resuscitation, was not performed until about nine minutes into her arrest.
Up until a cardiac response team was called and arrived at Mrs Newton's bedside, about five minutes into the emergency, Mr Scott said he found events were orderly and appropriate. Baby Romeo was born on his own during this first five minutes.
A member of the cardiac arrest team, Dr Chen, a junior doctor of three years' experience, had performed intubation before, but only under supervision or on mannequins, and never in a crisis.
She made the conscious decision not to intubate, choosing instead to use another resuscitation method, using a bag and mask, while others performed cardiac massage on Mrs Newton.
As this was happening, Dr Chen and another doctor called out for an anaesthetist to be telephoned, but the actual call was not made. At the same time, fortuitously, anaesthetist Dr Miller arrived out of his own initiative and intubated Ms Newton immediately.
Dr Miller said in his evidence he believed Dr Chen was right not to attempt intubation.
Mr Scott said he also believed she was right not to attempt to intubate, given her level of experience, the size of the embolism and that there was an alternative, if inferior, method available.
He found the treatment of Mrs Newton to be "reasonable and appropriate in the circumstances" but that it did not come quickly enough.
He had a number of issues with how things were done.
There was an uncertainty as to the timing of events, and he believed Dr Chen should have called Dr Miller immediately when she decided not to intubate, some five minutes before she called out, and he coincidentally and simultaneously arrived.
There was a lack of indication to doctors as to what they might expect when an emergency call was put out, most thought it was an emergency regarding a baby.
The team of people attending Mrs Newton did not have a clear leader in that roles were not pre-designated. The most senior or skilled person was expected to be the leader by defacto. This manifested when two doctors called for an anaesthetist to be phoned, and it was assumed anyone not already engaged would do it, but not clear if anyone was free to do so, or if everyone assumed someone else would do it.
Lastly, he said that the standard of note-taking during and after the emergency was poor, inconsistent, and short on details. Dr Chen made no notes at all. "That there should be improvement in record-keeping goes without saying".
Mr Scott concluded that Mrs Newton had suffered a "sudden, catastrophic event" in which her lungs filled with amniotic fluid, which prevented oxygen from getting into her bloodstream.
While it was possible that intubation, the "gold standard" of resuscitation, might have ensured her survival, "I believe, in reality, there was almost no chance of Tonia surviving - no matter what was done at the critical point in time."
Mr Scott said the hospital could take a number of things from his conclusions, but he would not be making a formal recommendation.
He said there was significant information in the decision for Wanganui and other hospitals to consider and assess whether their own protocols needed to be changed and he would have the findings circulated with this in mind.
Mrs Newton's mother, Karen McIntyre, said the outcome was what they expected.
"It's been a long time. I don't think I'll ever have closure. It's just not something that you ever have when you watch a child die."
She felt that there had been too much emphasis put on Mrs Newton's chances of survival.
Help for mother
not fast enough
It was irrelevant to the inquest, she said.
"People seemed to have it in their heads that she was going to die anyway. No one should assume that someone is going to die; they should be given the chance to live."
Peter Newton, Mrs Newton's father-in-law, said the coroner did remark on the slow speed of her assistance but felt that there should have been more emphasis on the significance of the first few minutes of her resuscitation, the first five in particular.
They both hoped Mrs Newton's death would mean new practices were put in place at the hospital to ensure it never happened again.
At the beginning of the inquest, Wanganui District Health Board counsel Adam Lewis apologised to the Newton family and said the root cause analysis into the circumstances of Mrs Newton's death could have been done better.
Co-ordination of the resuscitation should have been better, but the core elements of an appropriate resuscitation, namely adequate ventilation - oxygenation by positive air pressure and chest compressions, were done in a timely fashion. Analysis identified a number of improvements that could be made to the hospital's processes.
AdvertisementAdvertise with NZME.
Latest from Whanganui Chronicle
Whanganui Weather: What to expect this weekend
'It might be wise to bring an extra layer if you’re out and about.'