Medics’ neglect could have saved life: Report

LAHORE – On-duty doctors and paramedical staff could have been more vigilant and should have contacted the senior doctors to avoid the demise of 10-year-old Muhammad Suleman, says a report submitted by the enquiry committee of the Mayo Hospital on Wednesday.
The committee was constituted by the Medical Superintendent Mayo Hospital Dr. Fayyaz Ahmad Ranjha on July 06 to look into the death of Suleman on July 5. The committee comprised Prof. Paediatric Surgery Prof. Muhammad Afzal Shaikh, head Paediatric Medicine Prof. Muhammad Ashraf Sultan, Prof Anaesthesia Prof. Abdul Qayyum, AMS–OPD Dr. Shagufta Zaidi, Chief Nursing Superintendent Sharaf Sultana and Additional MS Dr. Muhammad Tanveer Ahmed. The report was to be finalised within three days, but it was submitted on July 20, 2005.
The committee observed that the Duty Nurses Amber Zareen and Shahida Khan did not respond positively to complaints of the deceased mother. According to the findings, Suleman remained drowsy through out the post-operative period and did not improve upon his conscious level as was expected by the medical staff. Although his vitals had been normal, but he was not fully responsive as he should have been after recovery. Suleman’s mother had been trying to feed him during this period, but he vomited. On the other hand, the committee could not find entry of any drug, which could have explained his drowsiness. The doctors and nurses could have been more vigilant in evaluation of the patient’s condition and should have informed the senior colleague in the operation theatre. Moreover, the anaesthesia team should have been more vigilant to assess the degree of recovery. The committee noticed that as the child had congenital deafness and could not speak, perhaps it could have some association of more congenital anomalies, and that might have been one of the factors of his prolonged drowsiness and inability of the staff to precisely evaluate his status of consciousness.
The committee is of the opinion that the cause of death could have been aspiration pneumonia. “However the exact cause can be determined with post-mortem examination, which was not done as the circumstances didn’t allow. This perhaps is a case of error of judgement on the part of the nurses and doctors who were involved in the management of child,” the report said.
Staff nurses Nasreen Raheem and Mussarat were suspended and Dr. Ali Abbas was terminated. However, Mussarat joined the duty after the aggrieved family had withdrawn its complaint against her.
10-year-old Suleman died on July 5 after a grafting surgery on his hand – injured by a cracker. The surgical was performed on July 4 by Dr. Naeem Noor under the supervision of Associate Professor Dr. Sajid Hameed Daar. Dr. Naila, Dr. Fareeda gave general anaesthesia. The surgical procedure was smooth, and according to the anaesthesia team, the child recovered from anaesthesia and was later shifted to the ward. The team comprising Dr. Arsalan Wasti, Dr. Farhan, Dr. Ali Abbas (terminated on July 5 for his negligence in this case) and Dr. Khalid were on duty on that day. Nurse Musarrat Fareed, who received the child, noticed that the child was drowsy, which she thought was normal post operative phase. She handed over the child to the on-coming evening shift duty nurse Amber Zareen in the same condition. Dr. Khalid, who examined the child in ward, noticed that the child was responsive to painful stimuli, but was sleepy. Suleman was subsequently seen by Dr. Farhan, who maintained that his vitals were normal and he omitted injection nelbin, which was not given before and advised the nurse not to give any sedation as the child was still drowsy. Suleman remained in the same condition till 4 am of July 5, when he was examined by Dr. Ali again, who realising that Suleman was unexplainably drowsy for over 12 hours, shifted him to emergency. SMO Dr. Naila was called from operation theatre to evaluate the patient at 10:30 am. She noticed that his vitals were normal and was responsive to painful stimulation.
While the child was given treatment as per Dr. Naila’s advice, Dr. Shoaib noticed that the child’s condition had deteriorated suddenly. He had breathing difficulty. He started to take appropriate measures, but his condition continued to further deteriorate and went into cardio-pulmonary arrest. All efforts were made to resuscitate, but unfortunately Suleman died at 12:30 pm (July5, 2005).
Suleman ‘s father Ehsan Ullah Chohan, a staffer of Daily The Nation, said the committee had done nothing by suspending a nurse and doctor. “They had killed my son, but the committee has done nothing in this regard. It must have approved a registration of criminal case against all those concerned. If they cannot figure out the problem in 24 hours, why are they working there? Dr. Ranjha assured me on that day (July 5) to take strict action against the culprits, but this is not the justice they meted out to me,” said inconsolable Chohan. “I will go into litigation against them as their negligence had caused the death of my son,” he added.