‘Our Annie’: Coroner, family call for changes after death of pregnant mother

The family of pregnant mother Annie Moylan are calling for a public inquiry into the state’s private hospitals after doctors failed to identify that she was suffering from sepsis before she died.

The 37-year-old’s parents, Brian and Marg Moylan, said their daughter was given appalling treatment after arriving at Holmesglen Private Hospital’s emergency department while unwell and 18 weeks pregnant in 2017.

On Tuesday, State Coroner John Cain found Moylan – also known as Annie O’Brien – might still be alive if she had been given antibiotics within an hour of arriving at the private ED where she was suspected of having a gastro, and not a fatal sepsis infection.

He called on the health department to make it mandatory for private hospitals to undertake root cause analysis on all unexpected deaths and ensure medical staff were aware of how to identify and treat sepsis in pregnant women.

The Moylans, though, said the changes needed to go further, with more Victorian lives at risk unless a full inquiry is held. They vowed to campaign to ensure that basic standards of care and accountability took place in the state’s private hospitals.

“Our daughter is not coming back, but we are very, very determined that people who go into the private hospital system are safe,” Marg Moylan said.

Grieving parents Brian and Marg Moylan outside the Coroner’s Court on Tuesday.Credit:Justin McManus

“It’s Annie that’s driving that. It’s our beautiful daughter who is no longer here and no longer has a voice.”

Moylan was 18-weeks-and-five-days pregnant when she arrived at Holmesglen Private Hospital’s emergency department, in Moorabbin, shortly before 7.30pm on August 14, 2017.

She had been suffering from vomiting, pain, a high temperature and diarrhoea for much of the afternoon and was diagnosed with a suspected case of gastroenteritis soon after her arrival.

When her condition worsened and her membranes ruptured, she was transferred to St Vincent’s Private Hospital shortly before midnight, where her private obstetrician Vicki Nott worked.

Annie Moylan died from sepsis in 2017 after doctors failed to diagnose her.

Moylan miscarried shortly after 2am. She went into organ failure herself and later died at 1.55pm.

Guidelines show that due to her symptoms, Moylan should’ve been taken to the nearest emergency department after leaving Holmesglen. St Vincent’s Private had no ED.

An autopsy later revealed she died with septicemia before a subsequent inquest, held in 2022, found no antibiotics were administered to the unwell women until seven hours after she first arrived at a hospital.

On Tuesday, the coroner found Moylan’s greatest chance of survival would have been if antibiotics were administered before 8.30pm on the night she arrived at the Holmesglen Private’s ED.

Cain found that up until 10.15pm gastroenteritis was a reasonable diagnosis for Dr Hui Li Shi to make at the Moorabbin hospital.

Despite this, he found it was unlikely, even with the intervention of antibiotics, the 37-year-old would’ve survived.

“Dr Shi should’ve known gastro was not likely to be the cause of the membrane rupture and should’ve 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’ve been undertaken that would have prevented her death.”

Holmesglen private hospial in Moorabbin.Credit:Scott McNaughton

While not making specific findings about those involved in Moylan’s care while at both Holmesglen ED and St Vincent’s, Cain was critical of the limited procedures in place for informing staff about sepsis guidelines for diagnosis and treatment.

Cain said Holmesglen’s dissemination of this type of important information “lacked rigour and accountability” and he accepted evidence that the doctor there did not see the guidelines displayed 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’s healthcare quality and safety improvement agency – to add them to existing sepsis guidelines.

Outside the Coroner’s Court, Brian Moylan said his family still could not comprehend how they lost their daughter – an esteemed family lawyer – and unborn grandchild in such heartbreaking circumstances.

Moylan’s family are calling for an investigation into the state’s private hospital system.Credit:Justin McManus

He vowed to continue to fight for more accountability and better standards in the private healthcare system.

“We really need to have an overhaul and a proper and thorough inquiry. Systems are important, we can change those, and they do impact on outcomes,” he said.

“In our view [Annie’s] death was preventable and with reasonable … clinical judgement she would be alive today. She’d want a legacy of change above all else. Our Annie”

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