A fresh investigation finds there were several failures in communication, staffing and the application of protocols when Monika Mann was discharged from Fiona Stanley Hospital days after giving birth to twins.
Monika Mann died on May 15, six days after birthing twinsBut a second investigation uncovered several failures
The hospital proposed a second investigation, still internal, but including a consumer representative and healthcare practitioners from interstate and other hospitals. The report also found "limited appreciation of differing cultural expressions of pain and discomfort may have resulted in a misunderstanding of what the patient was trying to convey, and increased patient dissatisfaction with post-natal care".It has recommended a review of the education provided to staff in pain management and differing cultural aspects and care expectations.
Patient advocate Suresh Rajan, who helped highlight the systemic failings that contributed to the death of seven-year-old Aishwarya Aswath at Perth Children's Hospital, said this case and others demonstrated the "absolute, pressing need" for a medical ombudsman in WA, a system which already exists in other states.
Mr Rajan wants an expedited public coronial inquest into Ms Mann's death, as happened with Aishwarya. "Listening to and gathering feedback from families is an important part of our processes and the family of Mrs Mann was closely involved in the second review.""One of the areas of feedback from the family was around culturally appropriate care and we are learning from that by enhancing existing education to staff about communicating with patients from diverse backgrounds.
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