Michaela Perrin: Coroner finds care 'grossly inadequate'
A YOUNG mother who died just days after giving birth at Lismore Base Hospital from a treatable infection received a "grossly inadequate" level of medical care, a coroner has found.
A NSW coronial inquest has been examining circumstances surrounding the death of Michaela Perrin, 26, due to a sepsis infection on October 22, 2014, six days after giving birth to her third child Brittany, via caesarean section.
Ms Perrin was discharged from the northern NSW hospital on October 19, three days after giving birth, but returned to the hospital the next day with symptoms including severe abdominal pain and "hot and cold flushes".
Instead of being admitted, Ms Perrin was sent away from the hospital with pain killers but returned the following day in a rapidly deteriorating condition, before dying on the morning of the 22nd in her hospital bed.
Handing down her findings, Deputy State Coroner Harriet Grahame labelled the care provided to Ms Perrin at Lismore Base Hospital as "grossly inadequate", but said improvements had been made since her tragic death.
"These are necessary changes and show some understanding of the serious gaps in care demonstrated in the evidence before me," Coroner Grahame told Glebe Coroners Court.
"In my view the Northern NSW Local Health District has now made significant improvements in the care it offers, albeit some years after Michaela's tragic death."
Coroner Grahame was particularly critical of the care provided by obstetrics and gynaecology registrar Dr Cristina Penaneuva, one of a number of doctors and nurses who treated Ms Perrin in the days leading up to her death.
She said Dr Penaneuva's failings included not taking notes in relation to her assessment of Ms Perrin, not identifying sepsis as a possible problem, not taking vital signs like temperature, and not assessing pain in her uterus.
"Dr Penaneuva showed a wholly inadequate knowledge of sepsis, particularly as it can occur post caesarian," Coroner Grahame said.
The Coroner also critiqued Dr Penaneuva's evidence given at the inquest, describing her as "not a reliable witness" and recommending that the Health Care Complaints Commission consider investigating her clinical conduct.
"At times she seemed confused and unable to answer straightforward questions. It was difficult to tell if she was nervous or somehow impaired. There were times when her answers appeared self-serving, inherently implausible and even untruthful," Coroner Grahame said.
The Coroner paid special tribute to Ms Perrin's family, especially her mother Cathy, whom she said had shown outstanding "grace and courage" since the tragedy.
"I was greatly moved by the love the Perrin family had for Michaela and for the way they continue to care for her beautiful children. I thank Cathy Perrin for bringing to court a family photograph and for sharing with us the children's progress."
Cathy Perrin, in court for the findings, embraced Coroner Grahame at the close of proceedings.
Outside court, Cathy said she hoped steps were now in place so that her daughter's fate "would never happen to anybody else again".
"We're all human at the end of the day, but there was human error and now they're in the process of fixing the problems," she told reporters.
"We just have to now move on." - NewsRegional