A woman became pregnant but, sadly, an ultrasound confirmed a non-viable pregnancy. The woman presented to a public hospital with pelvic pain and vaginal
She went on to experience ongoing complications that did not subside for eight months. During this time, the woman was admitted to hospital at least six times — four were acute visits, and she received care from no fewer than seven individual providers.
During the course of her care, the woman experienced an infection, and required two blood transfusions. She continued to bleed, and the cause of the bleeding was
not assessed adequately until eventually she required activation of the major haemorrhage protocol and admission to ICU.