Attorney General Anand Ramlogan has advised that the South West Regional Health Authority (SWRHA) must "accept and admit liability for medical negligence" in the death of Chrystal Ramsoomair.

Accordingly, it must offer a financial settlement to her husband who Ramlogan said would be expected to use it for the benefit of her children.

Speaking at yesterday's post-Cabinet news conference, Ramlogan disclosed the findings of the investigation into the death which had sparked controversy and was further fuelled by the "suspension" of five doctors and five nurses and the subsequent firing of SWRHA CEO Paula Chester-Cumberbatch.

An independent panel was appointed to investigate the matter after doctors embarked on sickout action.

While he noted that there were "lapses" on the part of medical staff, by and large the Attorney General spared the doctors and nurses of direct responsibility in the death.

He placed the greatest blame on the management of the San Fernando General Hospital.

Ramlogan said the panel also found that the doctors, consultant Dr Ashmeed Mohammed and Registrar Dr Jaggernauth, were on-call for emergency duties, also had a clinic fixed with prearrangement appointment and "in addition to these duties the hospital management scheduled the elective Caesarean section surgery on the deceased at the same time".

Ramlogan noted: "As a result of a directive by the then hospital medical director Dr Anand Chattergoon elective Caesarean sections were booked when the unit was on-call."

"That the hospital's management scheduled an elective Caesarean section on the day when the unit was on 24-hour emergency on-call duty and had a prearranged gynaecology clinic to attend to, demonstrates poor planning and (poor) overall patient case management. It is not surprising that the consultant (who was on duty at the clinic at the material time) was not in attendance when the C section on the deceased was performed," he said.

He added: "The predictable inability of the hospital to devote proper attention to high-risk patients in accordance with standard operating protocols, practices and procedures is indicative of the fact that the modus operandi of the hospital fell short of what was expected and required. ... It is tantamount to anticipated non-compliance with standard practice and procedure."

The investigation found that there was a limited number of nurses to serve the entire ward, since one of the five nurses rostered to work the shift on the postnatal ward was absent. "Thus, there were merely three nurses and one nursing assistant to care for 24 mothers and their babies. This amounted to a ratio of one nurse to 12 patients," he said. Furthermore, "the evening sister (Mrs Chitan) said she was not apprised of the patient's condition nor was she informed either of the severity of the patient's illness or the decision to take the patient back to the operating theatre".

The Attorney General also pointed out that since there was no dedicated porter to the Maternity Department the medical intern (Dr Ragoonath) had to take the samples of blood to the laboratory for testing and wait there to bring the blood and blood products back to the ward for the patient. "This meant that no intern was then available to assist in the resuscitation of the patient," Ramlogan said.

Noting that Ramsoomair had experienced massive blood loss, he said there was a difficulty in the release of blood from the laboratory. This situation was worsened by the distance of the laboratory from the postnatal ward, causing "further delay in getting the blood for transfusion to the patient".

"The more disturbing aspect of this case appears to be the seemingly institutionalised administrative failings existing within the health sector. The failure, to supply, maintain, or manage basic medical resources within the hospital system in this day and age is as treacherous, as it is embarrassing. Even more distressing is the fact that this state of affairs now seems to be the fatalistic norm within the public hospital system, and our medical professionals are accordingly placed at a precarious disadvantage in discharging their duties to those they serve," Ramlogan stated.

The Attorney General said the panel found that the referral letter from private obstetrician, Dr Jehan Ali, to the Antenatal Clinic at the San Fernando General Hospital was "inadequate".

The letter contained no information with respect to either the patient's two previous Caesarean sections or results of haematological investigations and ultra scans.

Ramsoomair who was 29 years old, bled to death, leaving a husband, Lorne Ramoomair, a five-year-old son, Christian; an 18-month-old daughter Sarah and the newborn, Danielle behind.

Ramlogan said while the actual reason or cause of death has not been shown to be the direct result of any action or omission on the part of the medical staff, "the growing body of medical jurisprudence does suggest that whilst it may not be possible to identify a direct or single act, error or omission on the part of the medical personnel that caused or led to the death of a patient, inferences can be properly made in appropriate cases where institutional failures and shortcomings justify a finding of medical negligence".