Report on Ramsoomair's death suggests medical staff didn't follow rules

The Sunday Guardian says it has obtained a copy of the report into the probe of the death of Chrystal Ramsoomair at the San Fernando General Hospital, which revealed that health care personnel failed the 29-year-old mother of three.

The paper said the report stated that the medical team did not comply with the necessary standards of care issued by the Ministry of Health.

Ramsoomair had a Caesarian section at the hospital to deliver her third child on March 4, 2011. Complications developed later and she died after emergency surgery.

The Guardian said the report states the following:

• 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, the paper said, listed the cause of death as a result of Hypovolemic shock, status post caesarean and status post hysterectomy.

And it blames the state for staff shortages and lack of medical equipment, saying they were contributing factors to the death of the woman.

It listed them as:

• Delay in initially obtaining blood and blood products from the laboratory due to the National Blood Transfusion Service policy
• Shortage of both medical and nursing staff at the obstetrics department
• Unavailability of essential equipment and emergency drugs to arrest the hemorrhage

The paper said the investigators recommended that the South West Regional Health Authority (SWRHA) should urgently deal with the problem of staff shortages at the Obstetrics Department and appoint a qualified manager for the maternity department.

It said the duties of the manager should include:

• Proper administration and governance in the department
• 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.

The report also recommended that the human resource manager consider the appointment of a dedicated labour ward consultant to manage the ward as well as a dedicated attendant/porter for the maternity department.

Attorney General Anand Ramlogan is reviewing the report, the Guardian said. It added that Ramlogan will report to the public once he has completed reading it.