ABBOTSFORD HOSPITAL: Stillbirth results in criticism, apologies
Doctors concerned more deliveries not backed by resources
A communication lapse between doctors and a delay in getting a patient into surgery for an emergency caesarean section led to a stillbirth at Abbotsford Regional Hospital that prompted an inquiry by the College of Physicians and Surgeons of B.C., changes in procedures and an external review this fall.
The 2016 stillbirth of Amari Mankatala will play a prominent role in the November review of obstetric capacity at the hospital because ever-increasing numbers of babies are being delivered there and, as in the stillbirth case, there was only one operating room available, one on-call obstetrician and a lone anesthesiologist on duty at the time.
The Fraser Health-commissioned review has tasked experts from Interior Health and the B.C. Women’s Hospital to investigate whether care is — or at risk of — being compromised by existing hospital resources like operating rooms, nurses, doctors and health-support staff.
“It’s triggered by concerns about increasing volumes of deliveries,” said Dr. Peter Beresford, Fraser region head of obstetrics and gynecology.
“My particular concern is that the more babies you deliver, the more chance of something bad happening. It’s a function of numbers,” added Beresford, noting that in the past two years alone, the volume of deliveries at the hospital has gone up 10 per cent. “Ten years ago, there were 1,500 babies delivered at Abbotsford hospital, but now, because of population growth, we’re at 2,600 each year.”
The Mankatala baby stillbirth follows three other critical incidents this year involving Abbotsford hospital patients who died unexpectedly. Earlier this year doctors sounded the alarm about hospital overcrowding.
A confidential college report into the complaint by Alisha Mankatala about her baby’s stillbirth was obtained by Postmedia News. It says the cause of death was asphyxiation (oxygen deprivation) during Mankatala’s labour/ delivery and it singles out a radiologist, Dr. Shivani Gupta, for criticism while not finding fault with the on-call obstetrician or the anesthesiologist.
Gupta failed to advise the obstetrician on call — Dr. Jason Kim — about a worrisome ultrasound done on the expectant mother when she first came to hospital in labour at 41 weeks’ gestation. Two hours passed between the time of the abnormal ultrasound and when baby Amari was removed from Mankatala’s womb. Kim was juggling multiple cases that day and had he immediately been told about the fetal heartbeat abnormalities, he would have expedited the Mankatala C-section even more, the college inquiry committee said.
Beresford said if an obstetrician receives a phone call about a dropping heart rate, “it triggers a completely different pattern of behaviour.” When there is no such call, “a sense of urgency is lost through the failure of physician to physician communication.” Gupta told the college she normally does phone the maternity nurse or the obstetrician. She acknowledged her oversight, conveyed her sympathy and made apologies to the Mankatala family. The college didn’t penalize Gupta, but criticism of the radiologist will remain in her record with the regulatory body.
Gupta’s actions, the college noted, didn’t “significantly delay” Kim’s receipt of the results and once he did get them, he made the decision to perform an emergency C-section. But it was a Sunday, he was juggling various emergencies and only one of six operating rooms at the hospital was suitable because it was the only one the lone anesthesiologist was working in.
Since the stillbirth, Mankatala has spent more than a year tracking down and digging into medical reports, filing complaints and going through another round of invitro fertilization to get pregnant again. Her emotional well-being has mostly recovered, but in the year after the stillbirth she avoided visits with friends and their babies as “it was a harsh reminder of what was missing by losing Amari.”
Psychological counselling helped Mankatala heal, but other strategies were crucial, too; Facebook was off-limits because she couldn’t view pictures of others’ babies and so was TV because of diaper and other baby commercials that triggered tears. Three months ago, during a planned C-section, Mankatala, a financial adviser at the Royal Bank, delivered a healthy baby at Abbotsford hospital with a different medical team. Her new baby, Ariella, has “filled” her broken heart, but Mankatala admits that Ariella’s milestones are sometimes a harsh reminder of “all that we’ll never see Amari reach.”
Recalling the harrowing experience, she says: “The ultrasound showed that the amniotic fluid was a little low, there was fetal heartbeat deceleration, but I was reassured that I was in hospital, the safest place to be,” she said in an interview.
“I was lying there waiting for Dr. Kim and for an open operating room. When the baby was delivered, he wasn’t crying, my husband (Ajay) was panicking, they were giving the baby epinephrine and doing chest compressions for halfan-hour. But he had suffocated to death right before birth. An autopsy was done at B.C. Women’s Hospital and it showed that he was (otherwise) perfect.”
Mankatala’s complaint to the Fraser Health Patient Care Quality Office resulted in apologies and regrets that the C-section didn’t happen sooner. A patient safety review was conducted and certain changes were implemented including pledges to improve communication between the OR and the maternity unit and more communication between the maternity unit and the neonatal unit on complex cases.
Mankatala said she knows nothing will bring back her first child (conceived through invitro fertilization) and she doubts she’ll ever fully overcome her post-traumatic stress disorder.
It took almost a year after she submitted her complaint to the college to receive an 11-page, “final-disposition report” prepared by a committee made up of eight doctors and four members of the public. Her complaint to the College of Registered Nurses of B.C. has still not been concluded.
Mankatala said she filed that complaint because a nurse failed to keep fetal health-monitoring equipment consistently attached to her while she was waiting for the C-section. Had that been done, the grave condition of her baby could have been revealed and the obstetrician would have known that he didn’t have a 30-minute window to attend to another birth nor wait for the operating room that was in use by another surgeon, she contends.
The College of Physicians and Surgeons of B.C. found no fault with Kim.
“... Dr. Kim could not have reasonably predicted that Mrs. Mankatala’s infant would be born with such significant compromise ... the devastating reality of obstetrical practice (is) that despite diligent practise and reasonable clinical decisions, a small percentage of devastating fetal outcomes occur.”
Complaints about medical care — and ensuing apologies — have become more common in the health-care system. Beresford, who previously apologized to another couple in the Fraser region who also lost a baby because of a devastating series of errors, said he would never minimize the loss of any family’s baby.
“It’s an awful, awful situation,” he said.
He agrees with Mankatala that monitoring equipment should have been kept on her consistently. Nurses working in the labour and delivery areas throughout Fraser Health have been reminded of that. Beresford said all health-care teams, like those working in obstetrics, must at all times have “situational awareness,” so they can be prepared for cases to suddenly become emergencies.
Beresford said he knows that doctors in various surgical specialties may have some angst about the upcoming external review and will naturally worry that more resources to obstetrics may come at the price of less resources for general surgery, for example.
“The patient with a ruptured appendix, the accident victims with broken bones, those waiting for urgent gallbladder surgery, those are all priorities, too,” he said.
Beresford said cases like this one are extremely difficult, but feedback and complaints from patients help make health professionals accountable. They remind health professionals about the importance of continuous quality improvement.
“We can’t have any tolerance for bad outcomes. We have to set benchmarks for patient care and safety high so we can always strive towards the goal that nobody dies in our hospital during labour and delivery,” he said. “Obstetrics is unpredictable and you can’t necessarily rescue every patient, but when they’re in your hospital, your goal should always be to try to do that.”