Healthcare systems failed pregnant mum Annie O'Brien and her family have been burdened with investigating what led to her death, her father has told an inquest.

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 had gone to Holmesglen Private Hospital with vomiting, diarrhoea, sweats and a fever less than 24 hours earlier, after no improvement from rest and paracetamol advised by her obstetrician.

Hui Li Shi was the sole doctor in the full 10-bed department that night and took an hour to see Annie.

With a temperature of 40.3C she was diagnosed with gastroenteritis and given fluids.

When her membranes spontaneously ruptured at 11.30pm Dr Shi thought it was the fever and gastro causing a miscarriage.

She told the Victorian Coroners Court on Monday that she hadn't considered sepsis, which ultimately caused Mr O'Brien's death.

"You have to make a clinical judgment. As a clinician, I made that judgment at the time unfortunately. I'm sorry."

With the benefit of hindsight, she should have thought whether something else was going on, Dr Shi said.

Ms O'Brien was transferred to St Vincent's Private Hospital where she delivered her baby stillborn at 2.12am.

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 the prescription was written.

After surgery, plasma and platelets she went into cardiac arrest. She was resuscitated but continued to deteriorate.

It wasn't until a doctor advised family 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," he said.

Life support was turned off at 1.55pm.

Her death was avoidable, he believes.

"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," he said.

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."

Participation in reviews by Safer Care Victoria is voluntary for private hospitals, but that changes from November.

SCV's patient safety review manager Megan Goadby said neither private hospital reported Annie's death but both provided some documents for an external review.