Following are the emails, obtained by Newsday, which began moments after Boodoo- Ramsoomair’s death.
To: Paula Chester -Cumberbatch
Date: Fri, Mar 4, 2011:
Cc: Dr. Lackram SWRHA BOD-Chairman Bodoe
Subject: Lost another obstetric case tonight
Not good news. Lost another obstetric case tonight. Third Caesarean Section--postpartum haemorrhage--Hysterectomy--still bleeding in spite of blood components--death.
Doctors involved--Drs. Ashmeed Mohammed, Roma Jaggernauth. Intensivist--Dr. Peng. Patient's name was Chrystal Ramsoomair, age 29 years.
She died in the ICU in spite of vigorous supportive measures. Baby is fine.
More details tomorrow.
From: Paula Chester-Cumberbatch To: Dr. Anand SWRHA Chatoorgoon
CC: Dr. Lackram SWRHA BOD-Chairman Bodoe" Dr Akenath Misir; Seeromanie Rampersad- Debideen; Geraldine Lewis; Nalini Parasram; Dr Anthon Cumberbatch.
Subject: Lost another Obstetric case tonight
Date: Saturday, March 5, 2011,
Dear MD (Ag) and Colleagues, Thanks for this timely update. Please ensure all reports are written up by the doctors and nurses (GM Nursing is also copied) asap and the patient's medical file and notes secured. I have copied our EMD and Manager Quality as well with a request to follow-up as necessary/accordingly.
The EMD is also advised that he is required to orchestrate the necessary Mortality Review exercise, as the report from this Review would be required for submission to the Maternal & Infant Mortality & Morbidity Oversight Committee (being finalized through the Board). Please be reminded that a final report would be required within 60 days (maximum) for the Ministry of Health (MOH) in keeping with the MOH Adverse Events Policy (4th draft).
Finally Anand and Seromanie, please ensure the family is offered and receives counselling, and that proper/correct information is shared with the family. Do also advise me asap if you perceive any discontent by the family. Respectfully, Paula Chester-
Cumberbatch CEO, SWRHA Cc: Chief Medical Officer, MOH
From: Anand Chatoorgoon
Date: Sat, March 5, 2011
To: Paula Chester-Cumberbatch
CC: Dr. Lackram SWRHA BOD-Chairman Bodoe" Dr Akenath Misir; Seeromanie Rampersad-Debideen; Geraldine Lewis; Nalini Parasram; Dr Anthon Cumberbatch.
Subject: Re: Lost another Obstetric case tonight
I have spoken with Dr Ashmeed Mohammed and Dr Peng, requesting that all reports from the relevant doctors be submitted to me by Wednesday morning. The postmortem will be done on carnival Monday morning by Professor Daisley. I shall attend and give you an update. In the meantime, I have issued verbal instructions that not only must the O&G Registrar be present in the theatre when Caesarean Sections are being performed, but also they must actually scrub for the case. In the particular case in question, the Caesarean Section was performed by a house- officer and not a Registrar although it is true to say that the house-officer has acted as Registrar in the past.
Will keep you updated.
From: Paula Chester-Cumberbatch
Date: Sat, 5 March 2011 To: Dr.Lackram Bodoe; Dr Anton Cumberbatch
CC: Dr Akenath Misir; Seeromanie Rampersad-Debideen; Geraldine Lewis; Beverly Reid-Samuel; Allyson Cudjoe; Dr Anand Chatoorgoon
Subject: Lost another Obstetrics case tonight
Dear Chairman and CMO: After all I have since heard on this maternal death, it is quite clear to me that we have breached the MOH Policy on the management of high-risk cases. By breach, I am noting that the Registrar 'failed to observe the Policy' whereby a house officer is not to perform a c-section alone in high risk cases. This patient was indeed 'high-risk' as this was her third c-section.
For me this shows gross complacency and negligence by the senior doctor involved and what the SWRHA has not done before, I will need to address with the assistance of the new Board. Specifically, dismissal of staff on grounds of medical mismanagement, with a covering HR/Legal Policy established.
I was told the Registrar responsible was in Clinic at the time of the c-section. Was the patient's need for a c-section on Friday morning an emergent situation?
Until I read the reports, my lay-- woman response is no. Hence it could have been rescheduled by a few hours to fit the availability of the responsible Registrar, who gave clearance to the House Officer to proceed.
Shouldn't the House Officer have used her common-sense, that is mindful of the MOH Policy and the 'underlying level of risk' for the patient, to have this surgery re-scheduled based on the on the availability of her Registrar? The answer is yes.
On another note I am also concerned that nobody (doctor/nurse) picked up on the fact that the patient was pale and her vitals indicating something was going wrong. Her PM is scheduled for Monday so we know better what went wrong.
From a management perspective, the EMD is to orchestrate the necessary Maternal Mortality Review. You would read below that verbal instructions were given to the O&G Unit. This is to be reinforced in writing on Wednesday.
However, apart from this, please note instructions were also given to the ICU staff that they are to serve as 'gate-keepers' whereby unless the Registrar is scrubbed for the case, they are not to anesthetize any patient for a c-section.
Finally, a closure-meeting was held with the family and SWRHA (doctors, quality coordinator) this afternoon, and I was just informed that the patient's family feel that the doctors and the nurses were all negligent.
They were pleased with the treatment from the moment the problem was detected but feel that their relative died due to our delay, by both doctors and nurses, in recognising her deteriorating problem.
If they decide to take legal action, this would not be a case to defend.
Respectfully, Paula Chester-Cumberbatch CEO, SWRHA From: Paula Chester-Cumberbatch
Date: March 5, 2011
To: Dr Akenath Misir
CC: Geraldine Lewis; Beverly Reid-Samuel; Allyson Cudjoe; Dr Anand Chatoorgoon; Dr Akenath misir; Dr Lackram Bodoe; Betty ann Pilgrim; Seromanie Rampersd-Debideen; Bonnie Crawford; Ashmeed Mohammed; Pamala Maraj; Dr Anton Cumbertbatch
Subject: Prelim Meeting on Carnival Tuesda- Maternal Mortality Review (Lost another Obstetrics case tonight)
Dear Dr Misir and Colleagues, Further to my voice-mail message a few minutes ago, and given the serious nature of this case, I would like for your first Maternal Mortality Review meeting to be held this Tuesday, for which I will also attend. If this is convenient to you please advise asap, as well as the time for our meeting. This matter has me and I am sure all of us very perturbed, as we don't seem to be moving forward in O&G in terms of eliminating such MDG occurrences. Finally, as you know on Wednesday we have the Human Resources Committee meeting and on Thursday is Clinical Governance and Ethics Committee meeting.
My intent is for discussion to be held by these two Committees on this maternal death in terms enforcing, crafting or amending an HR Policy, to (a) formally/properly recognise medical mismanagement as grounds for termination, (b) determine system for verifying medical mismanagement, and (c) levels of disciplinary measures to be instituted.
All in keeping with the RHA Conduct Regulations. I/we await your response.
Thanks much. Paula Chester-Cumberbatch CEO, SWRHA