Health authority liable for mother’s death, probe finds

A probe finds there were lapses on the part of medical staff at the San Fernando General Hospital in the botched Caesarean section on a 29-year-old.

PORT OF SPAIN, Trinidad, Friday June 3, 2011 – An investigation into the death of a 29-year-old who died after a botched Caesarean section in a hospital here has concluded that a health authority in the country and must now offer a financial settlement to the woman’s widower.

According to Attorney General Anand Ramlogan, the findings by the independent panel indicate that the South West Regional Health Authority (SWRHA) has to accept liability in the death of Chrystal Ramsoomair. She bled to death in March after a C-section at the San Fernando General Hospital.

Disclosing the findings of the investigation which led to the suspension of five doctors and five nurses and the subsequent firing of SWRHA CEO Paula Chester-Cumberbatch, Ramlogan said yesterday that while the actual reason or cause of death has not been shown to be the direct result of any action or omission on the part of the medical staff, "the growing body of medical jurisprudence does suggest that…inferences can be properly made in appropriate cases where institutional failures and shortcomings justify a finding of medical negligence".

The Attorney General said while there were "lapses" on the part of medical staff, the doctors and nurses were not directly responsible for the death. However, he said, the panel found that the doctors, consultant Dr Ashmeed Mohammed and Registrar Dr Jaggernauth who were on-call for emergency duties, also had a clinic fixed with prearrangement appointment and "in addition to these duties the hospital management scheduled the elective Caesarean section surgery on the deceased at the same time". 

"That the hospital's management scheduled an elective Caesarean section on the day when the unit was on 24-hour emergency on-call duty and had a prearranged gynaecology clinic to attend to, demonstrates poor planning and (poor) overall patient case management. It is not surprising that the consultant (who was on duty at the clinic at the material time) was not in attendance when the C section on the deceased was performed," he said. 

He added that the predictable inability of the hospital to devote proper attention to high-risk patients in accordance with standard operating protocols, practices and procedures, is indicative of the fact that the modus operandi of the hospital fell short of what was expected and required...It is tantamount to anticipated non-compliance with standard practice and procedure." 

He said the investigation also found there was a limited number of nurses to serve the entire ward. 

"There were merely three nurses and one nursing assistant to care for 24 mothers and their babies. This amounted to a ratio of one nurse to 12 patients. And the evening sister said she was not apprised of the patient's condition nor was she informed either of the severity of the patient's illness or the decision to take the patient back to the operating theatre,” he reported.

The Attorney General said Ramsoomair had experienced massive blood loss and there was a difficulty in the release of blood from the laboratory. 

This situation was worsened by the distance of the laboratory from the postnatal ward, causing "further delay in getting the blood for transfusion to the patient", he added.

"The more disturbing aspect of this case appears to be the seemingly institutionalised administrative failings existing within the health sector. The failure to supply, maintain, or manage basic medical resources within the hospital system in this day and age is as treacherous, as it is embarrassing,” Ramlogan lamented.

“Even more distressing is the fact that this state of affairs now seems to be the fatalistic norm within the public hospital system, and our medical professionals are accordingly placed at a precarious disadvantage in discharging their duties to those they serve.” 

Ramoomair’s death left her newborn girl, five-year-old son, and 18-month-old daughter motherless.

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