Pregnant Woman Dies. State Failure.
Official investigations into the death of 29-year-old Chrystal Boodoo-Ramsoomair at the San Fernando General Hospital has revealed failure at the hands of doctors, nurses and the State.The findings of the report exclusively obtained by Sunday Guardian revealed that the medical team failed to comply with the necessary standards of care issued by the Ministry of Health to save the young woman. Boodoo-Ramsoomair who was expecting her third child, was admitted to the hospital on March 3. Boodoo-Ramsoomair, who underwent an emergency Caesarian-section operation at the Intensive Care Unit of the hospital on March 4, delivered a healthy baby girl. After complications, she later underwent surgery and died after massive blood loss on March 4.
Pointing fingers at the doctors and nurses, the official report stated:
· Failure of medical staff to recognise the massive blood loss in a timely manner.
· Lack of prompt and efficient intervention by both medical and nursing staff.
· Lack of routine observation of patient’s vital signs by nursing staff.
· Failure to abide by certain protocols, standards of care issued by the Ministry of Health and SWRHA.
· Inadequate written documentation in the patient’s notes by medical staff.
· Lack of early senior multidisciplinary involvement, such as the consultant obstetrician, consultant anaesthetist, Intensive Care Unit team and the evening sister of the maternity unit.
The report listed the cause of death as a result of Hypovolemic shock, status post caesarean and status post hysterectomy. The State, however, is not free from blame as staff shortages and lack of medical equipment have been noted as contributing factors to the untimely death of the young mother.
They are:
· Delay in initially obtaining blood and blood products from the laboratory due to the National Blood Transfusion Service policy.
· Shortage of both medical and nursing staff at the obstetrics department.
· Unavailability of essential equipment and emergency drugs to arrest the hemorrhage
Based on the report, Sunday Guardian learnt that the State is set to fork out millions of dollars in compensation to the family of the deceased. The report did not reveal whether disciplinary action should be taken against the doctors and nurses. The report is in the hands of Attorney General Anand Ramlogan, who will decide whether it will be forwarded to the Director of Public Prosecutions Roger Gaspard. The committee to investigate Boodoo-Ramsoomair’s death was chaired by University of the West Indies senior lecturer, Dr Bharat Bassaw and comprised deputy chairman of the Integrity Commission Justice Gladys Gafoor, North West Regional Health Authority chief executive officer Claudine Sheppard and Central Regional Health Authority’s Cecilia Hutson.
The recommendations
Based on the findings, the committee concluded the following recommendations.
It included:
· The SWRHA should urgently address the staff shortages at the Obstetrics Department.
· The appointment of a qualified manager for the maternity department.
The functions of manager the committee included:
· Proper administration and governance in the department.
· Conducting needs assessment in order to equip the wards with the necessary physical and human resources
· Ensuring clinical governance, audits, perinatal and maternal morbidity and mortality reviews are done
· Monitoring the implementation of three appropriate policies, protocols and guidelines.
· Ensuring that all staff, both medical and nursing, engage in continued professional development.
· Establishment of an effective multidisciplinary committee to include obstetricians, midwives, paediatricians, anaesthetists and others such as a quality control officer and a medical records officer.
It was also recommended that the human resource manager consider the appointment of a dedicated labour ward consultant to manage the ward from 8 am to 4 pm (Monday to Friday) as well as a dedicated attendant/porter for the maternity department.
· They also recommended that the Registrar on-call Obstetrics must stay on the compound for the full 24 hours. The committee recommended that this may be possible with the hiring of two qualified Registrars for each unit.
· The terms and conditions of employment of consultants employed to allow for extended hours of coverage at the Obstetrics department.
· It was also noted that all Heads of Departments of Service Units must ensure the implementation of protocols issued by the Ministry of Health and SWRHA with immediate effect.
AG perusing report ...he’ll be ready by month’s end
Contacted last night, Attorney General Anand Ramlogan said he had not completed his review of the report because he had two full days in Parliament last week. “But I have started reading it and I shall report to the public once I have completed reading it.” Ramlogan said he would be out of the country this coming week and upon his return would complete his reading by month’s end.
Health Minister: Let justice take its course
Contacted last night, Minister of Health Therese Baptiste-Cornelis refrained from commenting on the report, only saying: “How did you obtain a copy of the report? I am going to let justice take its course.”
• In conclusion, however, the committee stated that the panel strongly recommends that maternal and child health should be given top priority.
The setting up of an immediate establishment of a Confidential Enquiry into Maternal deaths and infants deaths should be considered. “Recommendations on ways of improving healthcare in this country must be heeded. Substantive recommendations in the Gafoor report in relation to maternal and child health which were not implemented to date should be noted and serious consideration should be given to ensure immediate implementation,” the report suggested. No country shall acquire first world status if maternal mortality rate exceeds 50 per 100,000 live births and perinatal mortality rate is greater than 25 per 1,000 total births, the report noted. “These are the stark realities in our country today. We must address this immediately!” the report added.