A heartbreaking voice note was shared on a social media group and though I haven't heard from the other side, similar stories in the past reinforce my belief that more accountability in our healthcare system is badly needed. First some background, a summary of the voice note to put things in proper context. The narrator, herself pregnant had accompanied a pregnant woman to a government owned hospital in northern Nigeria. The narrator mentioned that after the patient was examined, they were informed the foetus was lying in an abnormal position and there were several failed attempts to 'turn the baby' to allow for a normal delivery. Following these attempts to turn the baby (that most likely failed, as) she was informed she would need a cesarean section (C/S) yet the patient was left in labor for 3 days with no form of pain relief. She was only taken for a C/S after the fetus was confirmed dead. The narrator mentioned that the patient was put in antishock garment at some point before surgery, suggesting she was in a critical condition.
The narrator also mentioned that whilst they were waiting for the patient to have the C/S, they approached one of the doctors on call to remind him about the planned C/S and he told her he'd just finished 3 C/Sections and had no plans of operating on her patient. There was no mention of what the next steps are for the patient.
She eventually had the C/Section after a new doctor came on call and told them the success of the surgery was 50/50 and the patient sadly died a few days after. They were informed that at surgery they found a ruptured uterus.
In closing, the narrator's voice cracking in what sounded like grief stricken voice said (paraphrased), "why do we only label armed attackers as killers and not healthcare workers because they literally killed this lady".
As I make my submission as a Quality Improvement and patient Safety (QIPS) advocate, I wish to again state that I'm judging from the statements in the voice note and without hearing from the other party (the hospital).
1. Who attempts turning a baby at term long after 'the water broke' when there are safer options? The uterus could have ruptured and the fetus harmed in the process
2. Every minute after 'the water broke’ increases the chances of infection for the the baby and mother and an indication to get the baby out fast.
3. It is criminal to allow a woman be in labor for 3 days and worse still without any form of pain relief. I've had 3 natural births and I don't wish anyone endure labor for longer than necessary and especially not lose their life or the baby's.
4. The patient and her relations were left in the dark as to the plans
5. This patient should have been seen by a specialist and or referred to a centre where she can be delivered safely if the first hospital is unable to do the needful.
6. This case should be subjected to root cause analysis (RCA) or similar meeting so it can be a learning process for quality improvement and patient safety (QIPS) structure of the hospital.
7. There should have been a post mortem examination and the findings be a basis to for improvement in maternal and child mortality data of the institution.
8. The patient's family should be a part of a very transparent RCA and post mortem and helped to find closure.
Let me emphasize here that one strong pillar of good QIPS processes is that punitive measures are a last resort unless the 'offender' has been found to be 'criminally negligent'.
There is no perfect health care system as every system makes mistakes but the best
use their errors as learning points to prevent a reoccurence of previous errors.
The question is how many health care facilities in Nigeria have functioning QIPS structure and are willing to open up their errors to scrutiny for QIPS? The Ministry of health has no formal/functional structure or law in place to support QIPS and we only hear of knee jerk responses for 'high profile cases' either because of the person involved or they got media attention. Thanks to social media and netizens.
As my title states 'Nigeria's health care is begging for accountability that was due yesterday'.
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Stories like this reminds me of why I became a quality and safety advocate. It's so unfortunate that incidence like this continue to happen. No woman (or child) should have to die of preventable causes. This is completely preventable. Imagine the trauma on the narrator who herself is pregnant. The ripple effect of this is scary.
Thanks for sharing.
Let`s patiently wait for the RCA of the incident.
may Allah grant the family succor from the grief.
Olabanji Mikail FISQUA