An Aliwal North woman has secured a R15m settlement from the Eastern Cape health department after the negligence of staff at two hospitals led to her baby being born with cerebral palsy.
Expert medical opinion sought by the health department when its lawyers were assessing whether to defend the claim concluded “it might be very difficult to defend this case” because of the “obvious substandard care” of not properly monitoring the foetus using a cardiotocography (CTG) test.
The department’s own expert said: “The absence of the CTG recordings is a breach of duty.”
The heavily pregnant woman was referred from Aliwal North Hospital to Frontier Hospital in Komani.
She was referred back to her home hospital as a “low risk” patient by Frontier staff but was never taken back, leaving her without critical care throughout the day as her condition deteriorated.
The woman (who is not being named to protect her own and her child’s identities) was 30 years old and expecting her first child in 2013.
She had four antenatal visits and everything appeared to be normal with her pregnancy.
On Friday, October 20, about 10 days before her due date, she was admitted to Aliwal North Hospital with “substantial” vaginal bleeding, and subsequently transferred to Frontier Hospital, where her baby was born the following evening by caesarean section.
At the Aliwal hospital, the mother-to-be was examined at 3.44pm on the Friday afternoon, when the foetal heart rate was normal and no bleeding was noted.
She was seen by a Dr Dababa about half an hour later, and the transfer to Frontier Hospital was arranged.
At 5.59pm she underwent a further vaginal examination in Aliwal, but there were no records indicating a foetal heart examination, according to a review of the records of both hospitals by Cape Town-based specialist obstetrician and gynaecologist Dr Michael Wright, who was asked to give a professional opinion by the health department.
There is no record of when the woman was first examined at Frontier, but a nurse noted she was contracting, with the cervix dilated at between two and three centimetres.
At 10.10pm she was seen by a Dr Ntuba, who confirmed the nurse’s observation and also noted, from an ultrasound, “a heavy show” of blood.
In usual circumstances this would indicate that birth was imminent, though in this case it was a “very suspicious” diagnosis, Wright said, because there were minimal contractions and the cervix was barely dilated.
A CTG test done on the foetal heart at this time was noted to be “reactive”.
The mother-to-be was next seen at 6am and 7am on Saturday, when she was experiencing lower abdominal pains and bleeding.
By 9.43am, the pain had stopped, foetal movement was good and the foetal heartbeat was normal.
Frontier staff then took a decision that the woman should be referred to Aliwal hospital as she was regarded as “low risk”.
But this was not done. And at 6pm on Saturday night, her cervix was dilated by three to four centimetres and there was evidence of amniotic fluid draining out from the woman which contained meconium (a foetal stool).
At 6.30pm, another CTG test was done, showing the foetal heart rate to be abnormal, and a caesarean section procedure was immediately ordered, but only started at 7.50pm, completed sometime after 8pm, though the mother was still in surgery at 9.30pm.
Wright said the delay in proceeding with the caesarean section was also unacceptable.
“There is no evidence that anything was done during this period to monitor the foetal condition or to improve it. This is also substandard care.”
The baby was suctioned at birth and required resuscitation. The mother lost over 1,300 millilitres of blood and required a transfusion, surgery to repair a vaginal tear, and a uterine stimulant to control bleeding.
Wright records that there were minimal notes on the entire surgery, and no reason at all was given for the excessive bleeding.
He said it was probable that antepartum haemorrhage — bleeding in the genital tract before birth — had occurred, and he did not rule out placental separation as the cause.
This typically happened in about 2% of pregnancies, he said.
If these and other clinical elements were considered, including the fact that the baby was “mature”, and that the mother was experiencing abdominal pain and waist ache, an induction of labour should have been considered.
He said it did not appear there was regular foetal surveillance during her stay at Frontier.
He said the notes from the surgery, limited as they were, had major discrepancies which raised suspicions.
“The notes tend to suggest a simple operation ... But the blood loss is noted to be 1,300ml, which is excessive and the question is where all of that blood came from.”
He questioned why the mother was still in surgery over an hour after the caesarean section had presumably been completed.
“Given the obvious areas of substandard care in this case that probably could be related to causation, as well as the details around the caesarean section, it might be very difficult to defend this case,” Wright advised the health department.
The settlement agreement between the woman and the department was made an order of court in the Bhisho high court on Tuesday.
The mother was awarded a total of R15m — R13.4m for damages on behalf of the minor child, R500,000 for herself and R1.08m for the costs of a trust to manage the award for the child and ensure permanent future medical and other care.