Bathurst caesarean blood policy urged is for all of NSW

"Do we have to wait for another mother to die in similar circumstances ... before there is some change?" asked Deputy State Coroner Carl Milovanovich on Friday.

He was handing down the findings of his inquest into the death of Rebecca Murray, 29, who died after the caesarean birth of her healthy third child at Bathurst Base Hospital in June 2007.

She died of multi-system organ failure following postpartum haemorrhage - excessive bleeding after the delivery.

The coroner said the hospital failed to check her blood type and ensure it had adequate supplies before the caesarean.

This meant some supplies had to be sent from Orange Base Hospital - 55km away - under police escort.

"Had a full blood count, group and hold and/or cross matching been done, Mrs Murray would have received blood transfusions at an earlier time and her death would have been prevented," Milovanovich said.

He also said the recovery room nurse had been inadequately trained.

Instead of immediately calling for help when Mrs Murray's blood pressure and pulse dramatically changed, she felt the priority was cleaning up the blood the patient was losing.

The coroner stressed the responsibility rested "squarely on the shoulders of hospital administrators" to ensure appropriately skilled staff were available for patients.

"The evidence has also established that there were individual failures by the medical and nursing staff, however, those failures are more of a systemic nature," he said.

At the start of the inquest on June 1, NSW health authorities apologised to Mrs Murray's family, informing them that Bathurst Base Hospital now enforced the new blood count and supply policy.

But Milovanovich was told this practice had not been implemented across NSW.

"If the unexpected and avoidable death of a young mother at Bathurst justifies a change in policy at Bathurst Base Hospital, why should that policy not extend statewide," he said.

He recommended Health Minister JOhn Della Bosca consider implementing a uniform policy in NSW hospitals in this regard for all elective and emergency caesarean sections.

In a statement, Della Bosca passed on his condolences to the Murray family and said he would carefully consider the coroner's recommendations to further improve patient care and safety.

"It is important that we take all steps to ensure the problems that occurred in this case will not be repeated as far as possible," he said.