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.
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.
Delay in initially obtaining blood and blood
products from the laboratory due to the National Blood Transfusion Service
Shortage of both medical and nursing staff at the
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.
Based on the
findings, the committee concluded the following recommendations.
The SWRHA should urgently address the staff
shortages at the Obstetrics Department.
The appointment of a qualified manager for the
The functions of
manager the committee included:
Proper administration and governance in the
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 mortality 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
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.
perusing report ...he’ll be ready by month’s end
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.
Minister: Let justice take its course
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 realities in our country today. We
must address this immediately!” the report added.