Ramsoomair, mother of three, gave birth to a baby girl at the San Fernando General Hospital via caesarean section on 4th March, 2011, and died hours later.
The investigations were conducted by an independent panel and while speaking at a post-Cabinet news conference last week, Ramlogan informed of the investigation’s findings which led to the suspension of five doctors and five nurses and the subsequent firing of SWRHA CEO Paula Chester-Cumberbatch.
Ramlogan said, 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 whilst it may not be possible to identify a direct or single act, error or omission on the part of the medical personnel that caused or led to the death of a patient, inferences can be properly made in appropriate cases where institutional failures and shortcomings justify a finding of medical negligence”.
The AG said there were “lapses” on the part of medical staff, the doctors and nurses were not directly responsible for the death. Ramlogan said the panel however 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 prearranged appointments and “in addition to these duties the hospital management scheduled the elective Caesarean section surgery on the deceased at the same time”.
He said, “As a result of a directive by the then hospital medical director Dr Anand Chattergoon, elective Caesarean sections were booked when the unit was on-call.”
“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: “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 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 (Mrs Chitan) 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.”
The AG said Ramsoomair had experienced massive blood loss but 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”.
“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. 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,” Ramlogan stated.
Further, the referral letter from private obstetrician, Dr Jehan Ali, to the Antenatal Clinic at the San Fernando General Hospital was also “inadequate”. The letter contained no information with respect to either the patient’s two previous Caesarean sections or results of haematological investigations and ultrasound scans.
(Parts of this article were written with content submitted in a Caribbeannewsnow publication)