THE Coroners Court of Victoria has found a Gordon woman’s death in 2004 shortly after giving birth was unpreventable.
The finding, handed down Tuesday, cleared Ballarat Health Services of any involvement in the death of Mary Korzeniewski.
Instead, coroner Audrey Jamieson found the 37-year-old died of a lack of oxygen to the brain after a cardiac arrest during routine surgery due to an undiagnosed hole in her heart.
Ms Jamieson found Ms Korzeniewski delivered her first baby, Tommy, naturally on December 26, 2004, but was transferred to theatre for manual removal of the placenta during which she suffered a heart attack.
She was resuscitated after 40 minutes, and a hysterectomy was carried out due to profound bleeding before she was transferred to the Intensive Care Unit.
However, tests showed Ms Korzeniewski had suffered irreversible brain injury and she died three days later.
“I find that the precursor to Mary’s collapse was an embolic event unrelated to the management of her labour, peri-natal period and decision regarding the need to proceed to manual removal of placenta in the operating theatre under a spinal anaesthetic,” Ms Jamieson said in her findings.
“There was a lack of clinical indices that might have alerted her healthcare providers to what was to occur or indeed to what caused Mary’s profound collapse.”
Following the finding, Ballarat Health Services chief executive officer Andrew Rowe said BHS offered its deepest sympathies to the family.
“Clearly this was a sad and difficult time for the family involved,” Mr Rowe said.
“Following Mary’s death, BHS reviewed its processes and implemented a number of changes to procedures.
“BHS continues to review and update its procedures.”