PROBE BABY SIMEON’S DEATH
By CAROL MATROO Tuesday, June 17 2014
Attorney General Anand Ramlogan yesterday said the report on baby Simeon will be referred to the Director of Public Prosecutions (DPP) to determine any criminal culpability in the circumstances that led to his death.
Copies of the report will also be referred to acting Commissioner of Police Stephen Williams to also consider for investigation, and to the Medical Board of Trinidad and Tobago to determine if there was need for disciplinary action against doctors who were involved in the patient management and care of the baby and his mother.
The Attorney General (AG) made this announcement during a news conference at Cabildo Chambers, St Vincent Street, Port-of-Spain, where he also officially presented the baby’s mother, Quelly Ann Cottle with a copy of the report.
Baby Simeon died from bleeding due to a gash to the head while being delivered during a Caesarian-section at Mt Hope Women’s Hospital, on March 1.
An independent committee, chaired by retired Justice of Appeal Mustapha Ibrahim and including United Kingdom specialist Dr Melanie Davies and retired neo-natologist Petronella Manning-Alleyne, was appointed by Ramlogan to investigate the baby’s death.
After being presented to Cabinet last week, Prime Minister Kamla Persad-Bissessar established an interministerial committee to review the report.
It was under the Prime Minister’s instructions that the AG gave a copy to Cottle and her family.
Yesterday, Cottle admitted that she felt a bit better now that she was finally seeing some results.
“I am happy thus far with what is going on. It’s kind of hard that it took so long to come, but so far I have no complaint. I am a lot happier now than before because I can now see things are happening,” she told reporters.
Cottle said if after the investigation anyone was found culpable, they should be held accountable.
“Nobody should have to go through this because it was hard to see my baby head cut, it was hard for me to deal with. I was told I shouldn’t jump in the face of God, but I asked Him where He was at that time,” she said.
Asked if she would be taking any further action against the hospital at this time, Cottle said she would first have to go through the report before saying anything further.
In the medical conclusion of the report, it was stated that inadequate measures were taken to manage the infant and to replace his blood loss. It added that the paediatric registrar and consultant appeared unable to recognise the need for their presence and provide the appropriate support.
Consultant Dr Mary Bhola-Singh, although informed of the ensuing developments, did not deem it necessary to attend the hospital, even when told about the infant’s death.
The committee stated that the consultant’s first duty of care was to their patient and would have expected that Bhola-Singh see Cottle personally following delivery.
“This is the 21st century. We have to come to terms with the fact that an educated and exposed population does not expect the medical care professionals to continue to stumble and fumble around with their children’s very lives and future,” the report said. It further stated that the paediatrician should not be expected to exhibit the same competency in dealing with the neonate (newborn baby) as the neonatologist.
On the issue of medical negligence, the report questioned whether the proper standards of skills and duty of care which a professional person was required to exercise as expected by law were followed.
In an adverse event incident form completed by Dr Javed Chinnia, who conducted the surgery and has been suspended, he listed the nature of the event as “a surgical event/surgical error resulting in death of the patient.”
The report stated: “Quite apart from the admission of Dr Chinnia, the nature of the injury sustained raises the issue of negligence which could not have been answered.”
The committee stated that given the entirety of the evidence it had come to the conclusion that the “error in judgement is one that would not have been made by a reasonable competent professional man professing to have the standard and type of skill that the surgeon held himself out as having and acting with ordinary care.”
During the inquiry, of the 27 witnesses directly or indirectly involved who were called before the independent committee to be interviewed, only one, Dr Nikshal Persad, declined to appear on the given date, but chose to attend on an adjourned date. But, this did not prove to be helpful to the committee as he only stated his name while his attorney advised that Persad had already given a statement at the hospital and had nothing more to add.
The committee said there were several matters on which Persad could have assisted them, but they were denied the opportunity.
The committee added that such a lack of cooperation from a professional person may amount to professional misconduct, advising that his employers should examine his refusal to testify.
During the press conference, Ramlogan said this was an issue that he did not intend to sweep under the carpet. He said there was an urgent need to ensure that senior doctors effectively supervised and monitored junior doctors who perform these operations.
“A C-section by itself is considered to be a fairly routine procedure but be that as it may, a C- section in this particular case may very well have clearly warranted the presence of a senior doctor.
“If it is diagnosed that this is a high risk pregnancy or a pregnancy that would give rise to complications, doctors must be on standby, not only junior, but senior doctors who could provide that level of experience and expertise to treat with any problems that may crop up,” he said. Noting that Chinnia was the one who seemed to be shouldering most of the blame, the AG was asked if Bhola-Singh would also be implicated.
“One has to look at the whole team of doctors that is responsible for the management and care of both mother and baby.
“If it is that the finding of negligence would apply equally to the consultant that felt this was not a matter that justified their call out, let the chips fall where they must. The medical profession needs to take stock of itself.
“Senior doctors are meant to make themselves available, perform their duties, make their rounds, meet with the nurses and junior doctors...it is not meant for a house doctor or registrar to be managing a patient in isolation, but rather as part of a team led by a senior consultant,” he said.