Attorney General Anand Ramlogan told reporters Thursday the South West Regional Health Authority (SWRHA) must accept liability in the death of 29 year old Crystal Boodoo-Ramsoomair.
And he said based on a report about the whole incident the SWRHA would have to compensate the Ramsoomair family for their loss.
And he said based on a report about the whole incident the SWRHA would have to compensate the Ramsoomair family for their loss.
The woman died at the hospital following a cesarean section to deliver her third baby. The infant survived.
The official cause of the death of Boodoo-Ramsoomair was massive post partum haemorrhage. Ramlogan said although the report did not list a single cause for her death, it highlighted serious institutional shortcomings as well inadequate compliance in international best practices in health care.
He spoke about some of the shortcomings that could have contributed to the woman's death, including human resources problems. He said doctors and consultants had been rostered to be at two places at the same time.
The official cause of the death of Boodoo-Ramsoomair was massive post partum haemorrhage. Ramlogan said although the report did not list a single cause for her death, it highlighted serious institutional shortcomings as well inadequate compliance in international best practices in health care.
He spoke about some of the shortcomings that could have contributed to the woman's death, including human resources problems. He said doctors and consultants had been rostered to be at two places at the same time.
In addition, the outgoing nurse failed to hand over cases to the incoming head nurse and absenteeism, which caused the nurse to patient ratio to be 1:12. He explained that best practice is for a 1:6 ratio.
The AG said there was also a lack of equipment such as a shortage of blood pressure monitors, no major haemorrhage trolley at the post natal ward, the absence of an oxygen line and accompanying attachment at the head of the patient's bed and the failure to check the clotting times for the patient.
He added that there was no intern to resuscitate the patient because the intern involved in the C-Section had to carry blood to the lab, which is located in another part of the Hospital.
"The fact that they scheduled that Gynaecology Clinic and put doctors who were on emergency call to do an elective surgery, all at the same time and on the same day, in my view, it demonstrated poor planning and overall case management by the San Fernando General Hospital," he said.
The AG said there was also a lack of equipment such as a shortage of blood pressure monitors, no major haemorrhage trolley at the post natal ward, the absence of an oxygen line and accompanying attachment at the head of the patient's bed and the failure to check the clotting times for the patient.
He added that there was no intern to resuscitate the patient because the intern involved in the C-Section had to carry blood to the lab, which is located in another part of the Hospital.
"The fact that they scheduled that Gynaecology Clinic and put doctors who were on emergency call to do an elective surgery, all at the same time and on the same day, in my view, it demonstrated poor planning and overall case management by the San Fernando General Hospital," he said.
"The predictable inability of the Hospital to devote proper attention to high risk patients in accordance with standard operating protocols, practice and procedure, is in itself indicative of the fact that the modus operandi of the Hospital fell short of what was expected and required. In other words, the way the Hospital is set up and being managed and run was in itself, deficient and defective. "
Ramloghan also said the review panel's recommendations should be implemented as a matter of urgency.
"Failure to address these matters will continue to present grave risk and danger in the health care system to the patients at the San Fernando General Hospital. Given these shocking, distressing and embarrassing circumstances, in my view, the SWRHA must accept liability and responsibility in this case," the AG stated.
Ramlogan also promised to make the report available to the Medical Professionals Association of Trinidad and Tobago (MPATT).
Ramloghan also said the review panel's recommendations should be implemented as a matter of urgency.
"Failure to address these matters will continue to present grave risk and danger in the health care system to the patients at the San Fernando General Hospital. Given these shocking, distressing and embarrassing circumstances, in my view, the SWRHA must accept liability and responsibility in this case," the AG stated.
Ramlogan also promised to make the report available to the Medical Professionals Association of Trinidad and Tobago (MPATT).
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