Young mum's death after giving birth by c-section was avoidable, coroner finds

The coroner said Ms Perrin presented to the hospital emergency department complaining of wound pain on October 20, four days after giving birth by caesarean section and one day after she had been discharged.

Ms Perrin was sent home with painkillers but returned the next day with worsening symptoms and was admitted to the hospital's Women's Care Unit, where she was found cold and unresponsive on October 22.

An autopsy later found she died from septic shock associated with a serious bacterial infection in her caesarean wound.

The coroner recommended that obstetrics and gynaecology registrar Dr Cristina Penanueva, who treated Ms Perrin, be referred to the Health Care Complaints Commission for further investigation.

She said the doctor - who is no longer working in an obstetrics and gynaecology role - during her inquest evidence showed a startling lack of awareness in how to recognise sepsis and how serious the condition is.

"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," the coroner said.

She noted that the Northern NSW Local Health District had already implemented many of the recommendations sought by Ms Perrin's family in response to her death.

The coroner did, however, recommend that they consider using Ms Perrin's story of rapid deterioration from maternal sepsis as a case study for educating midwives and other staff.

AAP