A doctor has lost a bid to quash the findings of a coronial inquest, which determined that his failure to treat a new mother's rising blood pressure caused her to suffer a fatal stroke.
But a judge has expressed sympathy for the situation of obstetrician Dr Andrew Foote following damage done to the doctor's reputation by "unfair" findings about his diagnosis and treatment of Corrina Medway.
Ms Medway gave birth to twin girls at Calvary Hospital on May 19, 2011, then suffered a "massive" brain haemorrhage within hours.
The 32-year-old was transferred that night to Canberra Hospital for urgent neurosurgery, but she died three days later.
In a 2015 inquest, Coroner Margaret Hunter found that Ms Medway's blood pressure was dangerously high in the hours after she gave birth.
Ms Hunter said there was a critical period in which Dr Foote failed to give Ms Medway the appropriate treatment at Calvary Hospital.
"Dr Foote's failure to treat Ms Medway's acute pregnancy-induced hypertension ... resulted in her blood pressure continuing to escalate to a critical level which ultimately caused her cerebral haemorrhage and death," Ms Hunter said in her findings.
Ms Hunter was scathing of Dr Foote, saying he was "not being entirely truthful" at the inquest and that he "tended to blame others for what was basically his responsibility".
Dr Foote subsequently applied to have the inquest and all of its findings quashed, claiming a new inquest should be held.
He argued in the ACT Supreme Court that Ms Hunter had made a number of adverse findings about his diagnosis and treatment of Ms Medway without giving him the proper notice to respond.
Dr Foote said new expert evidence would cast doubt on the coroner's findings, and that Ms Hunter had not properly examined a number of factors that could have contributed to Ms Medway's death. These included a midwife's failure to make an emergency call after a particular blood pressure reading, and a delay in Ms Medway being transported to Canberra Hospital for emergency surgery after the stroke.
Dr Foote also disputed findings that Calvary staff had made him aware of two important blood pressure readings. He said he would have treated Ms Medway for hypertension in the lead-up to her stroke had he known of those readings when they were taken.
On Tuesday, Associate Justice Verity McWilliam said the coronial findings about Dr Foote's diagnosis and treatment of Ms Medway were "unfair, both procedurally ... and in substance".
She said Ms Hunter should have provided the doctor with the specific adverse comments she was going to make about him before finalising the coronial report.
"I accept that there are meaningful submissions he would have wished to put before the coroner and evidence he would have been able to draw to the coroner's attention," Associate Justice McWilliam said.
She said Dr Foote had known Ms Medway's blood pressure was elevated, but the findings that he had been informed specifically about two key readings were based on what she considered "tenuous" evidence.
The judge also found that there could have been a greater investigation into why a midwife did not make an emergency call at a particular point, and whether Calvary Hospital could improve its systems and communication between midwives and doctors by using a clearer maternity observation chart.
But Associate Justice McWilliam declined to order a new inquiry as she dismissed Dr Foote's application for the 2015 inquest and all of its findings to be quashed.
She said she was sympathetic to the personal consequences for the doctor and his reputation. A new inquest might conclude that Dr Foote's decisions were justified based on what he knew at the time, and that others missed a series of opportunities to prevent Ms Medway's death.
However, none of Dr Foote's arguments had created "a question mark" that warranted the central manner and cause of Ms Medway's death being explored again.
"Clearer documentation, improved communication and more efficient processes for transportation may all have produced a different outcome from the tragic one that ensued," Associate Justice McWilliam said.
"The findings regarding Dr Foote's treatment were made without his input, and I have found that to have been an error of law.
"However, the entire inquest has not miscarried and I am not persuaded it is in either the public interest or the interests of justice to revisit the circumstances of Ms Medway's death."
Associate Justice McWilliam noted that Dr Foote had been offered the chance to apply for judicial review, which could have resulted in particular findings being quashed.
But he had chosen not to, instead sticking with an application that could only have resulted in all of the inquest's findings being quashed had he been successful.
Shortly after news of Associate Justice McWilliam's judgment hit the media, Dr Foote released a statement thanking her for her "intellectual rigour" and for noting that he had been treated unfairly.