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 was al­so rec­om­mend­ed.

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 moral­i­tiy 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 re­al­i­ty in our coun­try to­day. We must ad­dress this im­me­di­ate­ly!" the re­port added.