INVESTIGATORS FINDINGS ON JUBILEE

A three-member panel that was appointed to investigate accusations of irregular conduct by Victoria Jubilee Hospital staff against an expectant mother whose baby eventually died, has found no one professionally responsible for the incident.
At the same time, the panel has recommended in its 27-page report, a copy of which has been seen by the Jamaica Observer, that steps be taken to improve overall efficiency and patient care at the West Kingston-based hospital.
The finding stemmed from a report by the Sunday Observer on August 3 of this year in which patients who used the maternity hospital complained bitterly of shoddy behaviour by staff. One of the complainants, Stacey Josephs, alleged that she was verbally and physically abused and “did not receive compassionate and comprehensive treatment as a high-risk patient”.
The South East Regional Health Authority (SERHA), which commissioned the probe chaired by Government Senator and attorney-at-law Sophia Fraser-Binns, and including veteran obstetrician and gynaecologist Dr Vary Leslie Jones, and nurse Dr Lilieth Grant, said that several interviews were conducted with staff members who were said to be involved in the incident. The complainant was also interviewed.
“They also did desk research into the protocols and procedures from the Ministry of Health to guide their deliberations. The panel deliberated over a month and took verbatim notes,” the report stated in its executive summary.
“The panel found that there was slapping of the patient, but this was done in the context of trying to awake her from her sleep. They, however, could not confirm that there was verbal abuse and could not attribute that the death of her child was due to any deficiency in the care given or to any person or group of persons who took care of her.
“The panel made recommendations to improve the customer service and human relations aspect of care to prevent a repeat of complaints of a similar nature,” the summary stated.
“Given the nature of the evidence, the investigating panel was unable to attribute liability or responsibility to any one person or group for the demise of the baby of Miss Stacey Josephs, or the allegations she proffered,” it said in its conclusion.
“From our interviews and the review of the reports submitted, there is apparent breach of the protocol for the care of high-risk patients. The fact that Ms Josephs attended the hospital as a primigravida (a woman in her first pregnancy), with an unknown history and high blood pressure, a higher degree of responsiveness to her care was required from her caregivers, which would have satisfied the monitoring requirement and enlist psychological and counselling services earlier.
“We highlighted the areas of breach, evidenced from the reports before it. Whereas it cannot be said that the treatment of Ms Josephs contributed to the demise of her child, it is evident that her general care was left wanting, as it did not consider the psychological and emotional environment or the state of mind that she was in. It is our view that failure to consider her in that light made it difficult to enlist her co-operation as the care process was too prescriptive.
“The ability of the medical team to have responded proactively and treated Ms Josephs based on her individual needs and condition was lost and, with the exception of being placed on the high-risk ward, she was treated mechanically, like a routine pregnancy. It is to be determined whether the combination of her elevated blood pressure, coupled with what could have been a maternal infection as evidenced in the high white blood cell count of mother and baby; and the general weakness in monitoring of the patient are factors which affected the outcome of the baby. Unfortunately, the mother opted not to have a post-mortem and, as such, [the] committee did not have the benefit to review any findings.
“Notwithstanding these uncertainties, the panel is of the view that Ms Joseph’s experience can be a lesson to the health team on the importance of managing each patient based on her specific conditions and indications, as well as the need for comprehensive, ongoing communication at all levels including the patient.”
Among the recommendations are for the establishment of an orientation programme for new and established staff members regarding health ministry policies, procedures and practices; sensitivity training and reorientation of staff on the special requirements of high-risk patients; the frequent auditing of health records documentation, which ought to be used to remind staff of the responsibilities in recording “vital” information; the hospital administration should prioritise the consideration of allocating staff to the ‘high-risk’ area and prop it up with the introduction of medical students and student midwives to better monitor patients; and ensure that consultants and senior registrars at the institution conduct their rounds, while also getting regular updates on all patients, but particularly those deemed to be of ‘high risk’.
Josephs, 32, claimed that when she was taken to the hospital in mid-June after suffering severe pain and with an elevated blood pressure, she was verbally and physically abused and did not receive the special kind of treatment that was required by a high-risk patient. She had gone to a private doctor who urged her to visit the VJH immediately.
Hospital authorities denied the claim, but Health Minister Dr Fenton Ferguson, nonetheless, ordered a probe into the allegations, after turning up at the hospital, unannounced, days before.
Josephs claimed that she was told by the doctor on duty that she was to blame for the death of her baby boy, as she was too fat and too lazy to push the baby out.
She also said that she was neglected for more than four hours, as a doctor had not seen her during the time, despite her condition.
“While I was in labour, the doctor looked at me and said that I’m so fat I did not know that I was pregnant and I need to hurry up and get the baby out because she needed to go home,” Josephs said in her statement.
“I was slapped, her colleagues laughed at me, I was in and out of consciousness. When I was going to the nursery, nobody gave me any direction or took me there. I had to walk to the nursery with a bag inside of me, because the baby had defecated in me. When I went there, he was stringed up. I asked what it was and the doctor just looked at me cold and said ‘nuh bother pay that nuh mind’ because I know anything can happen when I have sex, so I better call the father.
“Nobody told me anything. I didn’t get any explanation or nothing. It was a nurse who saw me crying and read my docket and told me two days later that it was the cord that was wrapped around his (the baby’s) neck. I was placed into a ward with a lot of babies and nobody offered me any counselling, nothing,” she stated.
The baby died 13 hours after birth.
In summarising the findings, the panel highlighted seven items of interest:
(1) There were general and specific breaches of the ministry’s protocol, which caused the care of the patient to fall below the prescribed standard for a high-risk patient.
(2) The communication between the patient and the medical and nursing staff was limited and prescriptive, rather than descriptive and socialising to enlist understanding and co-operation during the care process.
(3) There was limited communication between and among residents and their supervisors.
(4) There seems to be limited co-operation/relationship between departments (Nursery & Obstetrics).
(5) The patient was slapped on her thighs to arouse her from sleep during the birthing process. This practice is common. However, the manner in which the patient was physically handled might appear to onlookers as insensitive and abusive, but must be viewed in the circumstance in which it was done as well-intentioned to awake Miss Joseph to facilitate the birthing process.
(6) There appears to be a breach in the administration of dangerous drugs as well as administrative oversight at the ward level.
(7) Ms Joseph was treated as a low-risk patient and thereby her treatment was not as comprehensive as was expected, considering her specific condition. The approach was also mechanical.
The panel also highlighted what it termed “an apparent weakness” regarding communication by the medical team.
“It was quite evident that the junior staff took the decisions on their own without informing their seniors, which may be viewed as an error of judgement on their part. Although in some circumstances a medical officer can make decisions within his sphere of competence, without referring to the senior, in this situation, it would have been prudent for him/her to have advised the senior, given the special nature of Miss Josephs’ pregnancy. The continued lack of communication between the parties can cause the junior person to act outside of his sphere of competence without realising same.
“We, therefore, would wish to see improved communication and collaboration in the care of patients between and among residents, medical officers, senior registrars, and consultants. This should be in an atmosphere where each feels empowered to call upon the other at any time. Further, senior colleagues must ensure that junior doctors are not left on their own by doing regular 12 noon and 6:00 pm ward rounds on the labour ward and call in at an appropriate time of the evening or night to ascertain the status of the patients under their care.
“Additionally, the rules and policy affecting the duties of senior doctors must be complied with. The ministry’s Manual 4 provides that the consultant on duty that day, all the senior residents on duty that day must be informed of all high-risk patients. There was no evidence of an evening round, where all the residents and the consultant review patients. There was also no evidence of consultation between the junior residents and the seniors. We were convinced that had the senior registrar done the 6:00 pm labour ward round, and the consultant done his ‘call-in’, there might have been a difference in the turn of events.
“The investigating panel is of the opinion that this weakness in the supervisory support of the medical officers led to a breakdown in the clinical supervision of the patient, in that although the consultant was not called for guidance, there is no evidence that the senior resident or consultant was called in for an update on the patients on their wards. The panel noted that the baby was delivered by forceps. Whereas best practice requires that the resident consults the senior doctor, given the emergency, it is understandable that the resident made a judgement call to deliver the baby without first speaking with his senior. However, there is no evidence that the resident discussed this delivery, either with the consultant or senior registrar, post-delivery. The panel sees this as a misstep in the overall management of the patient. The panel reasonably concluded that if there was effective and ongoing communication between the junior doctors and their seniors, whereas the outcome may have been the same, the treatment in the management of the patient might have been different.”
The panel also pointed to a breakdown in clinical supervision on the ward among the nursing staff, where regular monitoring and review were not done.
“The evidence before the investigating panel pointed to a lapse in the general and specific aspects of care of the patient. The facts showed that Ms Josephs’ membrane was ruptured sometime after 11:00 pm and by 2:00 am she was fully dilated and placed in the delivery room. The progress of the labour to this point may be deemed satisfactory. However, the monitoring of both mother and foetus fell short of the prescribed procedure and acceptable standards. On review, the foetal heart was checked only three times at 10:55 pm, 12:00 am and 12:37 am. There is no record of monitoring done between 12:37 am and 2:13 am when the baby was born. There was also no record that the requested CTG was done. It had been proffered that the CTG was not done due to a shortage of paper, however, the panel found this excuse unacceptable as the requisite monitoring could have been done even in the absence of paper.
“The Ministry’s Protocol 7 speaks to the need for adequate management of the high-risk patient to include the monitoring of the mother’s blood pressure and foetal heart rate at specified periods. This was not done as specified. It is well recognised that public hospitals may not have the human resources at all times of the day to adequately monitor the foetal heart every 15 minutes as required by the said protocol. Notwithstanding, there is a need for greater and more effective use of ancillary and complementary staff, including student midwives and medical students, in these circumstances.
“The investigating panel, therefore, found that the patient had inadequate clinical monitoring between the period of rupturing the membranes and taking the patient to the delivery room, that is, between 11:30 pm and 1:30 am.
“The interviews revealed that, based on the evidence before the paediatric staff, there was the probability of an abnormal baby, with an abnormal brain or heart. However, this could have been better determined if continuous monitoring of the foetal heart rate was done and now remains a probability as there was no autopsy, thereby underscoring the importance of continuous and effective monitoring.”
The panel said that it also cited deficiencies in the dispensing of medication, as well as staff supervision.
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