Lost form linked to SA pregnancy death

A misplaced ultrasound form may have contributed to the death of a woman and her baby in Adelaide, a coroner has found.

But South Australia's Deputy Coroner Anthony Schapel says he can't be sure whether or at what point Mellanie Joanne Paltridge's survival could have been assured had her rare aneurysm been diagnosed after having the abdominal ultrasound.

Mrs Paltridge, 25, was nearly six months pregnant when she haemorrhaged three times before going into cardiac arrest during surgery at the Women's and Children's Hospital in 2012.

Her baby girl died a day later.

Mr Schapel says the surgery would have been significantly less complicated and the chance of cardiac arrest reduced had an ultrasound been preformed.

But this didn't happen because staff misplaced the test form and failed to "appreciate the degree of urgency required".

"The ultrasound would not be carried out at any time prior to Mrs Paltridge's final collapse and death," the deputy coroner said in his inquest findings on Wednesday.

Mrs Paltridge had collapsed in a shopping centre the day before she died.

When she arrived at hospital she was not seen by a senior doctor but assessed by medical staff who didn't have the training to spot the ruptured aneurysm in her spleen.

Mr Schapel said no medical practitioner who saw Mrs Paltridge was at a consultant level and those who did treat her had an "inadequate and imperfect grasp" of the features of a ruptured aneurysm.

"This was simply the result of a lack of awareness and professional development," he said.

"Mrs Paltridge should undoubtedly have been seen by a medical practitioner at consultant level."

Mr Schapel recommended that medical staff, including nurses and midwives, be taught to identify potential splenic artery aneurysms and that where such conditions are suspected, diagnostic tests be performed urgently.