That was the finding of Deputy State Coroner Carl Milovanovich, at the completion of an inquest into Ms Murray’s 2007 death, held at Westmead Coroner’s Court this month.

Mr Milovanovich also found Rebecca Murray did not receive the appropriate recovery nursing care required for a woman haemorrhaging after the birth of her baby.

Mrs Murray, 29 died at Nepean Hospital on June 25, 2007, 24 hours after giving birth to a healthy daughter, Grace, at Bathurst Base Hospital.

The cause of death was ‘multi-system organ failure following a post partum haemorrhage.’

When the inquest began on June 1, Greater Western Area Health Service issued an apology to the family of Rebecca Murray, saying they “are deeply sorry for the tragedy that the Murray family have experienced as a result of Rebecca’s death”, an apology the family described as ‘pathetic’.

Mr Milovanovich found the two main contributing factors contributing to Mrs Murray’s death were the failure to take a full blood count, group and hold and or cross match prior to an emergency caesarean section. The failure was due to both policy at Bathurst Base Hospital and a belief by the obstetrician that it would be done.

“Had a full blood count and cross matching been done Mrs Murray would have received blood transfusions at an earlier time and her death would have been prevented,” Mr Milovanovich said.

The second contributing factor in Mrs Murray’s death was “the care and treatment of Mrs Murray in the recovery room which failed to provide the appropriate nursing care for a woman who had suffered post partum haemorrhage, in that the allocated staff had no experience in identifying a continuing post partum bleed.”

As a result of the finding, Mr Milovanovich recommended the implementation of a uniform policy across NSW which ensures a full blood count and group hold be undertaken for elective and emergency caesarean sections.