Midwife referred to board after missing sepsis signs in postpartum death
A midwife who failed to identify developing signs of sepsis, including a persistent “offensive odour” in a woman who had recently given birth, has been referred to the nursing and midwifery board.
Gia Lam, 32, died from sepsis due to pyelonephritis three days after giving birth to her son at Sydney’s Fairfield Hospital in 2019.
An inquest was told she would have survived had UTI been diagnosed but that numerous opportunities to spot the infection were missed.
Among the issues was that communication with clinical staff also became difficult because no interpreter services were organised so Ms Lam, who was born in Vietnam, could not communicate effectively with medical staff, particularly in relation to the pain she was experiencing.
Deputy NSW coroner Rebecca Hosking said the first missed opportunity came during a hospital antenatal visit a few weeks before the birth.
Having complained of difficulty in urination, Ms Lam was encouraged to increase her fluid intake rather than investigated further.
When she was admitted to hospital for induction of labour, a urine dipstick test returned results that were not normal, although again no action was taken.
Ms Lam’s son was subsequently born with the aid of a vacuum-assisted delivery, during which she sustained a perineal tear that was then sutured.
The court was told that, the day after the birth, Ms Lam had complained to staff of a sore perineum but it was not found to be swollen when examined.
Later, she was prescribed Panadeine Forte after telling medical staff she was in “a lot of pain”.
The following morning, the pain persisted, but the inquest heard that, when a midwife checked Ms Lam’s perineum, there was still no swelling.
“[The midwife] reported that she was unable to educate Gia on perineal care and afterbirth pain due to there being a language barrier,” the coroner said.
On the day she was discharged from hospital onto the Midwifery Support Program, another midwife encouraged Ms Lam to have a shower, owing to a “very offensive smell”.
The midwife later told the coroner that she believed the odour could have come from an old sanitary pad or poor hygiene.
“[She] was not prepared to accept that the offensive odour was a possible sign of infection,” the deputy coroner wrote in her findings.
“Significance should have been attached to the odour, and it should have prompted both a mid-stream urine test and escalation to a medical officer.”
At home later that night, Ms Lam’s husband said she appeared to be in agony.
A midwife from the Midwifery Support Program visited the next day, but the coroner said Ms Lam did not have access to a translator, preventing her from accurately describing her level of pain.
The midwife observed that Ms Lam was “in a lot of pain”, “breathing quickly” and “appeared distressed”.
“Gia gestured, by way of pointing, that the pain was located in her neck and legs,” the coroner wrote.
“Gia then phoned [a friend] so that she could translate.”
The midwife assessed her physically and encouraged Ms Lam to shower, advising her to see her GP and to take paracetamol for the pain.
But the coroner said the midwife should have called an ambulance.
Although the expert evidence suggested that appropriate treatment at this stage may not have changed the outcome, the midwife later acknowledged she had failed to appreciate the severity of Ms Lam’s condition, particularly the abnormal severity of her pain, that it had spread to her legs and neck and that her breathlessness was significant.
“She properly conceded that she ought to have measured Gia’s respiratory rate and pulse, that she should have regarded Gia’s pain as concerning and that breathlessness was a potential indicator of infection,” the coroner wrote.
“She also accepted that recommending review by a GP, rather than advising immediate re-presentation to Fairfield Hospital, was an error.”
That evening, a friend found Ms Lam lying in bed with fluid on the floor.
She was taken by ambulance to Liverpool Hospital, where she became bradycardic. At 6.30pm, she went into cardiac arrest, and resuscitation efforts continued until 8.10pm.
The post-mortem found her cause of death to be sepsis caused by pyelonephritis of the right kidney due to acute and chronic cystitis.
More information: Coroners Court of NSW report; 17 Mar 2026.
