Doctors roster: The top part of the rotation roster for Mt Hope Maternity Hospital for March 2014.

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SURGICAL ERROR

C-section report handed to Health Minister states:

By BY Anika Gumbs CCN Senior Multimedia Investigative Journalist

The report into the death of a newborn baby whose head was cut during a Caesarean Section has stated that Dr Javed Chinnia, the surgeon who performed the surgery on mother Quelly Ann Cottle, listed the incident as a “surgical event/surgical error”.

The March 9 document sent to Health Minister Dr Fuad Khan is titled “Report into the death of infant of Quelly Ann Cottle” and was submitted by acting quality coordinator of the Mt Hope Women’s Hospital Laldaye Jadoonanan.

Page four of the report which was obtained exclusively by the Sunday Express states that following the March 1 surgery on Cottle, an “adverse event” incident form was completed by Dr Chinnia who highlighted the incident during Cottle’s C-section.

Her baby, named Simeon, sustained a cut to the head during the C-section and died hours later.

The report states: “Dr Chinnia listed the nature of the event as a surgical event/surgical error resulting in the death of the patient.”

The report quotes his description of the event as: “A Caesarean Section was being performed for delivery as there was severe intrauterine growth restriction. Routine procedure was followed. The lower uterine segment was first incised using the scalpel. The incision was opened with blunt dissection using a small artery clip. On delivery of the fetus a laceration about 3-4cm was observed across the scalp. The Paediatrician present was informed immediately as to was the patient.”

But in his statement to the North Central Regional Health Authority (NCRHA) board (under which the Mt Hope Women’s Hospital falls) on the surgery, Dr Chinnia notes that he spent about three hours after the C-Section “counselling” Cottle and monitoring her blood pressure after he was informed that the baby Simeon’s condition had worsened and the prognosis was poor.

His statement says that he observed there was an “injury” to the baby’s scalp. The surgery was performed on March 1 at 2.34 p.m.

 However, in Chinnia’s statement also obtained by the Sunday Express he does not list the baby’s head being cut as a surgical error.

His stated: “While performing the operation an injury to the fetal scalp was found at delivery and the Paediatrician was informed. The mother was also immediately informed as she was under spinal anaesthesia. The rest of the procedure was routine and a tubal ligation was also done as requested by the patient.”

 Chinnia’s statement read: “I remained in the operating theatre until the baby was transferred to the Intensive Care Unit.At 5 p.m. I left the compound to have some lunch. At about 5.45 p.m. I was informed that the neonate’s condition had worsened and the prognosis was poor. I then returned to the hospital at 6 p.m. The rest of the evening was spent counselling the patient and keeping a close watch on her blood pressure as she had a hypertensive disorder of pregnancy. Once she was stable I left at 9.15 p.m. to have a shower and I returned for rounds in the birth department at 11 p.m. and then went to rest.

 I then started ward rounds on my unit patients at about 5.30 a.m. on March 2, 2013 until 8 a.m. when we finished on the natal ward.”

The quality report also noted information listed in Chinnia’s statement and that of midwife Selima Mohammed.

 Section Three of the report said: “The Caesarean Section was performed by Dr Javed Chinnia when it was noted that the infant sustained a three to four centimetre scalp laceration likely as a result of the small artery clip used for blunt dissection of lower segment. However, the midwife’s report indicates the surgeon made a small smiley face incision and asked for a six-inch artery forceps which he used to extend the incision as per usual. There appears to be some conflicting information between the surgeon and the midwife’s report.”

And while questions were asked by the Dr Shehenaz Mohammed-led board as to why University of the West Indies (UWI) consultants Dr Bharat Bassaw and Dr Mary Singh-Bhola were not present during the surgery, the quality report did not list the reasons for the doctors being absent.

The UWI in a release last Wednesday indicated the it was not necessary for consultants to be present during the surgery.  

The release stated that one of the consultants was on leave while the other consultant remained on call. 

 The quality report said Bassaw and Singh-Bhola are consultants attached to Unit A of the hospital.

However, nowhere in the quality report does it state that Bassaw was to proceed on a leave of absence with effect from March 1 to 3.

The hospital roster obtained by the Sunday Express listed both Bassaw and Singh-Bhola as scheduled for duty on March 1, 2014.

 However, a note stating Bassaw’s leave of absence is listed below the roster.

Meanwhile, Singh-Bhola, who was asked to submit a report on her whereabouts during the surgery wrote:  “Unit A was on duty on March 1, 2014. I arrived at the hospital- Mt Hope Maternity Hospital at 10.30 a.m.  By that time ward rounds were completed. I was advised by the registrar of the various patients on the labour ward and the proposed management plans. I was also informed of the planned Caesarean Section scheduled to be performed later that day as was previously agreed upon on the patient Quelly Ann Cottle due to severe hypertension with associated fetal growth restriction.  I left the hospital at midday but was available for on-call (advice, assistance as needed).”

 Singh-Bhola said in the report that she was informed of baby Simeon’s injury.

“I was informed by the registrar of the injury which was sustained at the time of the Caesarean Section. At that time, the neonate was being managed by the paediatricians and no obstetric intervention was needed hence the reason for not coming. I was again called later that night to inform me of the subsequent demise of the neonate. I was called a few times later that night for advice regarding the management of other patients.”

The Sunday Express learned that Singh-Bola was not required to be at the hospital during the surgery.

A senior medical source yesterday told the Sunday Express that either a registrar or consultant is required for a Caesarean Section with assistance from a junior officer and a scrub nurse.

 Anaesthetic consultant Dr Ruth Ramkissoon was also cited in the report.

 According to the quality report, Ramkissoon learnt of baby Simeon’s death via a newspaper article five days after the incident. 

 “Dr Ramkissoon indicated in her report that she was the anesthetic consultant on call for the day but was not informed of the incident since it was not an anaesthetic-related matter. She further stated that her first knowledge of the incident was on March 6, 2014 when she read the newspaper article,” the quality report said.

The quality report also noted that the laboratory was not informed that a high risk patient was being taken to the theatre for a Caesarean Section.

 Listed also in the report is a summary of statements from members of staff who were on duty and on call on the day of the surgery.

 In its conclusion the report stated: “In the absence of a root cause analysis and clinical review no conclusion can be determined on the clinical aspect of the adverse event.”

The report also noted a need to closer examine compliance with the Ministry of Health Obstetrics and Midwifery Standard Operating Manual and on call coverage of the hospital by all consultants and registrars.

It was also recommended that an independent investigation be launched into the matter.



Medical staff on duty


Medical reports show that staff in attendance on the day were:


Surgeons: Dr Chinnia and Dr Meera Bissoon

Anaesthetist: Dr Viswaswara Rao Kurapati and Dr Angela Ofomata

Paediatrician: Dr Cara Ranghell 

Scrub nurse: Judith Edwards

Circulating Nurse: Crystal Henry

Midwife: Selima Mohammed

Rec room nurse: Sister Fareeda Khan.

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