She had been experiencing vomiting, pain, high fever and diarrhea for most of the afternoon and was diagnosed a suspected case of gastroenteritis shortly after her arrival.
When her condition worsened and her water ruptured, she was transferred shortly before midnight to St. Vincent’s Private Hospital, where her private obstetrician Vicki Nott worked.
Moylan miscarried shortly after 2 a.m. She went into organ failure herself and later died at 1:55 p.m.
Guidelines show that Moylan should have been taken to the nearest emergency department because of her symptoms after she left Holmesglen. St Vincent’s Private had no ER.
An autopsy later revealed she died of septicemia before a subsequent inquest, held in 2022, found that no antibiotics had been administered to the sick women until seven hours after she first arrived at a hospital.
On Tuesday, the coroner found that Moylan’s best chance of survival would have been if antibiotics had been administered before 8:30 p.m. the night she arrived at the Holmesglen Private’s ED.
Cain found that gastroenteritis until 10:15 p.m. was a reasonable diagnosis for Dr. Hui Li Shi to prescribe at Moorabbin Hospital.
Despite this, he thought it unlikely that the 37-year-old would have survived, even with the help of antibiotics.
“Dr. Shi should have known that gastro was not likely the cause of the membrane rupture and should have prescribed IV (intravenous) antibiotics,” Cain said.
“I am satisfied that by the time Annie arrived at St Vincent’s Private on August 15, 2017, her clinical condition was so serious that there was no medical or nursing management that could have prevented her death.”
While Cain made no specific findings about those involved in Moylan’s care while working at both Holmesglen ED and St Vincent’s, he was critical of the limited procedures in place to educate staff on sepsis guidelines for diagnosis and therapy.
Cain said Holmesglen’s dissemination of this type of important information “lacked accuracy and accountability” and he accepted evidence that the doctor was there did not see the guidelines posted anywhere in the hospital.
He also found that five years later there were still no uniform guidelines specifically for the treatment of sepsis in pregnant women and called on Safer Care Victoria – the state agency for the improvement of health care quality and safety – to apply them. add to existing guidelines for sepsis.
Outside the Coroner’s Court, Brian Moylan said his family still couldn’t fathom how they lost their daughter – an esteemed family lawyer – and unborn grandchild in such heartbreaking circumstances.
He vowed to continue fighting for more accountability and better standards in the private healthcare system.
“We really need an overhaul and a proper and thorough investigation. Systems are important, we can change them, and they affect the results,” he said.
“In our opinion, (Annie’s) death was preventable and with reasonable…clinical judgment she would be alive today. Above all, she would want a legacy of change. Our Annie”
The Morning Edition newsletter is our guide to the most important and interesting stories, analysis and insights of the day. Register here.