THE report into the Caesarean-section death of baby Simeon is to be sent to the Director of Public Prosecutions (DPP) for immediate investigation, Attorney General Anand Ramlogan said yesterday.
Ramlogan, at a news conference at the Office of the Attorney General in Port of Spain at which Simeon’s mother, Quelly Ann Cottle was present, said the report will also be submitted to the office of the Commissioner of Police for a “full scale investigation” into the facts and circumstances of the baby’s death.
The report will also be sent to the Medical Board of Trinidad and Tobago as part of the process of determining any disciplinary action against Dr Javed Chinnia, who performed the surgery and who has since been suspended.
Ramlogan said he also met yesterday with Prime Minister Kamla Persad-Bissessar, who was “very concerned” about the findings of the report and she has instructed Health Minister Dr Fuad Khan to look immediately into implementing its recommendations.
Ramlogan said the Prime Minister’s priority in this matter is that a similar incident never occurs again.
The PM also instructed Ramlogan to present the report to the family, which he did yesterday, handing over a copy to Cottle.
On March 1, baby Simeon died after his head was cut open during Caesarean section surgery at the Women’s Hospital of the Eric Williams Medical Sciences Complex.
Ramlogan appointed a team to probe the baby’s death and was presented with the report on June 6.
The team was chaired by retired Justice of Appeal Mustapha Ibrahim and included United Kingdom specialist Dr Melanie Clare Davies and retired neonatologist, Dr Petronella Manning-Alleyne.
In commending the team yesterday, Ramlogan said Government got what it wanted—an “independent, no holds barred” report.
Yesterday’s news conference followed an hour-long meeting between Ramlogan and Cottle, which he described as “heartbreaking”.
Answering questions later on, Ramlogan described the scenario of the baby’s death as “tragic” and “depressing” , adding that reading the report leaves one with a lingering sense of disappointment.
“Quelly Ann was cheated by the system,” Ramlogan said.
“Her loss is one that no mother, no father should ever have to bear.”
While the matter is now one for the DPP and for Cottle’s lawyers led by Farid Scoon, Ramlogan said the report veers clearly towards “negligence” on the part of the doctors and institution that managed baby Simeon.
Ramlogan declined to speculate on the outcome of the matter in terms of discipline and said that would be a matter for the DPP.
Among the recommendations of the committee is that junior doctors must be supervised but Ramlogan could not say yesterday whether the senior doctor on duty at the time of the Cottle death would be looked at as part of the investigation.
He said, however, “In this particular case, I think it is abundantly clear that the senior doctor should have been present to guide the junior doctor.”
He said senior doctors must make themselves available to nurses and junior doctors and in any profession, one who has just entered is considered “green”.
Ramlogan said he also does not know whether any finding of negligence will apply equally to the consultant but the management of a patient should be a team affair.
“The medical profession needs to take stock of itself,” Ramlogan said.
Recommendations of the Committee:
- The consultant on-call should be involved in all cases involving mortality or serious morbidity. Following a serious adverse event, the consultant should see the patient/parents involved. The consultant should provide support for the team involved in a traumatic event;
- Laboratory services are required around the clock; the availability of blood for transfusion is a priority;
- Clinical guidance protocols which address clinical management of all aspects of care of the mothers and babies should be developed;
- There must be adequate on-site supervision for all junior medical staff;
- There should be daily consultant presence on the maternity wards. The consultant on-call each day should undertake a formal morning ward round to review high-risk patients in delivery suite, antenatal and postnatal wards;
- Planned high-risk deliveries should be booked within weekday working hours where possible, to ensure that staff and resources are available. This applies to both maternal and foetal indications. However, clinical need is paramount.
- Planned deliveries should not be restricted to on-call days;
- \A second dedicated obstetric theatre is required. This would facilitate a greater possibility of having planned deliveries in a timely manner;
- Immediate review of resuscitation procedure with special emphasis on the response to acute blood loss and the use of adrenaline and sodium bicarbonate;
- Immediate provision of training in the care of small/tiny neonates with special emphasis on the infusion of fluids: quality, volume and rate; and
- Employ the appropriate professionals to deal with and to support the needs of neonate.