The death of a woman who suffered very rare complications during childbirth could have been avoided, a Hong Kong inquest jury has found as it returned a verdict of misadventure.

Jurors held in Friday’s ruling that Liang Jinxiao, 33, was administered excessive amounts of a labour-inducing hormone as doctors sought to deliver her baby through a procedure involving a vacuum device.

But Liang, a mainland China-born housewife, suffered an amniotic fluid embolism – a highly unusual event involving the fluid that surrounds a baby in the womb entering the mother’s bloodstream and causing a serious adverse reaction.

She died two days after going into labour and giving birth to her 38-week-old daughter at Queen Elizabeth Hospital in Yau Ma Tei on November 28, 2016. Medical authorities suggest the probability of those complications taking hold are as low as one in 100,000.

As part of their verdict, the five-person jury called for the Hospital Authority to produce uniform guidelines for public hospitals on the use of the oxytocin hormone and on the monitoring of patients during childbirth.

Her husband, civil servant Chung Tak-ling, said he was satisfied with the ruling but hoped the hospital could reflect on the incident and avoid similar tragedies.

“I think my wife died under questionable circumstances. You do not expect a woman to die in labour,” Chung said, adding he was considering taking the Hospital Authority to court over the incident.

Patient rights advocate Tim Pang Hung-cheong, who assisted Chung in the legal proceedings, said he was disappointed by the doctors involved as they refused to admit wrongdoing. He accused an expert witness of being overly sympathetic towards the hospital and failing to act impartially.

The Coroner’s Court heard that Liang had experienced profuse bleeding, low blood pressure and rapid heartbeat after giving birth at 9.41pm on November 28, 2016.

Her attending doctor initially found the bleeding normal, but an hour later realised the possibility of the patient suffering the embolism.

Despite emergency surgery to remove the uterus, Liang’s condition never improved. Physicians assessed that death was a certainty by the time she was sent to intensive care the next morning.

Patient rights advocate Tim Pang (left) and widower Chung Tak-ling (right) leave Coroner's Court.

Liang died on November 30 that year after her family agreed to withdraw her ventilator. She had lost a total of 16 litres of blood after multiple transfusions in the last three days of her life.

A postmortem examination revealed the woman’s circulatory system was contaminated by fetal cells and amniotic fluid, resulting in severe defects in blood coagulation.

The use of oxytocin – a hormone and neurotransmitter that facilitates labour – and a suction cup to assist delivery, were both identified as risk factors.

Doctors involved in the operation testified that they had followed established procedures when handling Liang’s case.

Consultant obstetrician Leung Wing-cheong, who served as an expert witness in the seven-day inquest, said it was unfair to hold hospital staff accountable, as the complications that arose were hard to detect.

He also suggested Liang’s severe response could have been the result of an underlying illness or other unknown factors.

But two other experts hired by Liang’s family countered by pointing to multiple shortcomings during the medical procedure, including a belated diagnosis, the excessive use of oxytocin, and proceeding with surgery to remove the patient’s uterus when her condition was unstable.

Most of the jury rejected Leung’s contention and found the death could have been avoided.

The panel also issued eight recommendations to the Hospital Authority, urging it to compile uniform guidelines on using oxytocin in all public hospitals and to ensure an efficient notification mechanism was in place along with closer monitoring of patients and improved training for medical staff.

In her direction to the jury, Coroner Monica Chow Wai-choo said: “The present incident shows that what is rare does not mean it will never happen. Would it be possible that [medical workers] had failed to give sufficient weight to [the possibility of a rare condition] when they made a diagnosis because it was so rare?”

Speaking to the jury before the verdict, Chung said he occasionally broke down in front of his now five-year-old daughter as he struggled to come to terms with his wife’s death.

“Because of this ordeal, I understand that the death of a labouring woman can deal a destructive blow to a family,” Chung said. “I wish I am the last person to endure this kind of suffering.”