Regulator clears nurse in stillbirth at Abbotsford hospital
College also identifies systemic factors that contributed to ‘traumatic outcome’
The College of Registered Nurses of B.C. has dismissed a complaint against a nurse involved in a delivery that led to a baby’s death at Abbotsford Regional Hospital.
The stillbirth sparked apologies, complaints and an external review of the hospital’s ability to provide safe care for obstetric patients, given the challenge of serving an area where the population is growing quickly. Abbotsford’s population (now about 150,000) is projected to grow three per cent a year. The number of births at the hospital has almost doubled in the past dozen years.
The 2016 death of Amari Mankatala occurred after a delayed caesarean section on a Sunday when only one anesthesiologist and one obstetrician were frantically working on multiple urgent cases. They had only one operating room available.
The baby’s mother, Alisha Mankatala, filed complaints after the death.
The College of Physicians and Surgeons of B.C. found a radiologist failed to call the obstetrician about an abnormal ultrasound done when Mankatala arrived at the maternity department.
That meant there was no sense of urgency for the obstetrician, who was attending to other patients.
The College didn’t discipline the radiologist but said the information would remain in her file.
Another investigation, by Fraser Health, is looking into the hospital’s capacity for obstetric patients.
The health authority ordered the review by external experts to answer whether care of obstetric patients in the fast-growing region is — or is at risk of being — compromised because of hospital resources such as shortages of physicians, nurses, operating rooms and other health support staff.
Natasha Dookie, deputy registrar of the College of Registered Nurses, the nurses’ regulatory body, said in a letter to Mankatala that the operating room nurse didn’t warrant any discipline because her actions met satisfactory standards.
In the letter, obtained by Postmedia, Dookie said the inquiry committee did note the other problems acknowledged by Fraser Health — shortages of medical staff and poor coordination and communication between staff, such that the Mankatala baby was not extricated more quickly.
Mankatala got to the hospital in early labour and in the few hours before the emergency caesarean section, there were several decelerations recorded in her son’s heartbeat, including one lasting for six minutes. When the obstetrician saw Mankatala, he realized a caesarean section was required but he couldn’t do it for 30 minutes because of other cases and the fact that only one anesthesiologist was on shift. Calling in someone else from their home would have taken the same amount of time.
Mankatala complained to the nurse’s College that she had an external fetal monitor attached to her belly in the operating room holding area but it was removed by the nurse in the operating room.
The College report said this was done “due to considerations of efficacy, positioning and sterility.”
The inquiry panel said it is not possible to have the monitor and its belt attached while a patient is getting an epidural catheter insertion “due to requirements to maintain the sterile field and necessary patient positioning.”
While Mankatala was being prepared for surgery, the obstetrician was working on two other urgent cases. But when the nurse noticed an abnormality in the fetal heart rate, she notified the obstetrician who was just completing a vacuum-assisted delivery on another patient. He rushed in but when the baby was delivered, there was no pulse and the baby could not be resuscitated.
The College committee said while it is restricted to investigating nurse conduct, it did identify “systemic factors that appeared to contribute to the traumatic outcome, including: an apparent failure to communicate the ultrasound results to the maternity ward and on-call obstetrician; the presence of only one anesthetist and obstetrician in the hospital when many labours were taking place, and three concurrent fetal emergencies.”
Dookie said in her letter to Mankatala: “Your complaint has provided (the College) and the inquiry committee with a sombre reminder of the significant impact of the resourcing and coordination challenges inherent in the provision of health care.”
The College apologized for its delay in investigating the complaint and issuing a report, saying it has had its own staffing problems.
“Our investigation took almost 24 months to complete which is longer than an investigation of a serious nature should typically take.”
Mankatala said in an interview that after all this time, she’s not surprised by the College report and just wishes that “someone would take responsibility ” instead of blaming her baby ’s death on limited hospital resources.
“A homeless person who has to steal because of their limited resources is held accountable but when it comes to my son’s life, a son I tried to have for several years … no one is held accountable.”
Since her baby’s stillbirth, Mankatala went through another round of in vitro fertilization to get pregnant. She delivered a healthy baby girl almost a year ago, a planned caesarean section at the same hospital.
A homeless person who has to steal because of their limited resources is held accountable but when it comes to my son’s life … no one is held accountable.