Five years to the day after the 37-year-old died, her father Brian Moylan has urged State Coroner John Cain to be courageous in pursuing facts around her death and to make bold findings toward improvements in Victoria's health system.
Ms O'Brien died from sepsis hours after delivering her baby stillborn at 18 weeks.
She fell ill with vomiting, diarrhoea, sweats and a fever less than 24 hours before her death. Her obstetricians office advised rest and paracetamol.
When her condition hadn't improved a few hours later she went to the emergency department at Holmesglen Private Hospital about 8pm with a temperature of 40.3C.
She was diagnosed with gastroenteritis and given fluids.
When her membranes spontaneously ruptured at 11.30pm the decision was made to call an ambulance and urgently transfer her to St Vincent's Private Hospital.
When her obstetrician arrived at 1.30am Ms O'Brien was agitated and confused.
At 2.12am she delivered her baby, stillborn.
Half an hour later, she was given her first dose of antibiotics - an hour after her obstetrician went to look up sepsis guidelines, and 46 minutes after he prescription was written up.
After surgery, plasma and platelets she went into cardiac arrest. She was resuscitated but continued to deteriorate.
It wasn't until a doctor advised them about 12.30pm that her condition was not survivable that they even realised the sepsis was life threatening, Dr Moylan told the Victorian Coroners Court on Monday.
"At no time were we advised that all of the close family members should be told to come in," Mr Moylan said.
Life support was turned off at 1.55pm.
Dr Moylan said his daughter's systems of care and clinical care failed her.
"Annie's death was avoidable," he said.
"The failure of effective regulation of private hospitals and private hospital EDs in Victoria was contributory in the circumstances that led to Annie's death."
Grieving families deserve to be given full information on adverse events involving loved ones, Dr Moylan said.
"I don't believe that we should have been burdened with the task of investigating the circumstances of our daughter's death," he said.
"I challenge this court to be courageous and to be forensic in pursuit of the facts concerning Annie's death and to make bold findings and recommendations toward improvements in the health system in Victoria."
Public hospitals are required to participate in reviews with Safer Care Victoria after patient deaths, but participation by private hospitals is voluntary.
Neither Holmesglen nor St Vincent's reported Ms O'Brien's death to SCV, but both provided some documents for an external review, SCV director Megan Goadby said.
From November SCV will have powers to compel all health services to provide original patient files and internal reviews, she said.
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