A doctor who provided "grossly inadequate" care to a young mother who died days after giving birth in a NSW hospital still doesn't seem to understand the magnitude of her failings, a coroner says.
Deputy state coroner Harriet Grahame has referred Dr Cristina Penanueva to the Health Care Complaints Commission following an inquest into the 2014 death of Michaela Perrin.
"Given the demonstrated gaps in Dr Penanueva's knowledge and her apparent lack of insight in relation to a number of issues I remain concerned that she does not understand the magnitude of her failings in relation to this death," Ms Grahame said at Glebe Coroner's Court on Tuesday.
Ms Perrin was 26 years old when she died from sepsis at Lismore Base Hospital while her healthy newborn daughter slept nearby.
Ms Grahame found she received grossly inadequate medical care and her death was potentially avoidable.
"Michaela's death is a terrible tragedy ... appropriate and timely medical care could have saved her life," Ms Grahame said in her written inquest findings.
"Instead, her three greatly loved children are being raised by her mother, and her family continue to grieve their loss."
Ms Perrin first presented to the hospital's emergency department complaining of wound pain on October 20 some four days after giving birth by caesarean section and one day after she had been discharged.
According to her mother, Cathy Perrin, who is a qualified midwife, she was in so much pain that she "couldn't stand up straight".
Dr Penanueva sent Ms Perrin home with painkillers but experts told the inquest she should have been admitted for tests and close observation.
The doctor failed to write any notes of her assessment, review the triage notes, take vital signs, properly assess the pain in Ms Perrin's uterus or identify the possibility of sepsis.
The coroner said when Ms Perrin returned to hospital the next day with a fever and severe pain, Dr Penanueva took steps she should have taken a day earlier.
Experts said it was obvious at that stage that Ms Perrin had sepsis and the situation was urgent.
The young mother was admitted to an inappropriate ward with an ill-equipped nurse who had not been told she was in a critical condition and needed frequent observations, the coroner said.
She was found cold and unresponsive in her hospital bed the following morning.
The coroner said Dr Penanueva - who is no longer working in an obstetrics and gynaecology role - showed a wholly inadequate knowledge of sepsis and a serious lack of essential medical knowledge.
She was not a reliable witness and at times seemed confused, giving implausible and even untruthful answers, the coroner said.
The coroner recommended the Northern NSW Local Health District use Ms Perrin's story of rapid deterioration from maternal sepsis as a case study for educating midwives and other staff.
Australian Associated Press