Confident it was an isolated case

The Chief Medical Officer at Auckland Hospital claimed a case of preventable death had a combination of circumstances that was unusual and he was confident it was an isolated case. Sounds like code for “it won’t happen again because it’s very unlikely”. That’s not an effective way to deal with repetitive failure - and preventable hospital death in New Zealand is definitely a case of repetitive failure, the national solution to which has been to take seven years to produce an incomplete report.

Auckland City Hospital admitted that the death of Renee Bayliss on January 26 withn 4 1/2 hours of the birth of daughter, who survived, was preventable. The report in the NZ Herald stated, “A first-time mother died from severe bleeding during childbirth after blood was not put aside for her, despite her specific request.”

The most galling aspect of this case was that the risk of haemorrhage was recognised before the commencement of induction and Ms Bayliss had requested cross-matched blood be put aside. That request was made on January 24: it wasn’t needed until January 26 but when it was needed it wasn’t there.

Key issues in care were identified as:

* Why she was not quickly given a transfusion of “universal donor blood”, whose higher risks are considered justifiable, rather than having to wait for blood cross-matched because of particular antibodies that had been injected before the birth. The anti-D antibodies are given if there is a risk of the mother’s immune system attacking the fetus’ blood cells.

* Whether a hysterectomy, to stop the bleeding, should have been done sooner.

The problem with these “key issues” is that they deal with conditions that happened as a consequence of earlier treatment - they do need to be addressed - but the real issues, in my view, are:

  • Number one issue - why was cross-matched blood not delivered until 6:17am on the 26th? (over a 32-hour interval)
  • Why did the patient have to request for blood to be put aside? Isn’t that what doctors are for?
  • On December 31st, “Her placenta was also found to be at risk of causing problems, including bleeding following birth.” Why did this information, of identified higher risk, not ensure that blood was ready and available?
  • Given the known risk of haemorrhage, why was induction started before securing the matched blood? More than three weeks had elapsed since original hospital diagnosis, so it shouldn’t have been an urgent induction.
  • “Although a registrar had asked at 4.15am for cross-matched blood to be provided, the request was not carried out.” Why not?
  • “The blood bank was not told a cross-match of blood was required until 5.20am.” What is happening here? Is there a communication problem with the blood bank? Not forgetting that they were advised of this same need more than 24 hours before.

The hospital has commissioned an external review. Hopefully that will arrive at uncovering the root causes of failure (tough to do after this much delay) - otherwise we will see this kind of preventable death recurring. An external review is better than nothing - but much better would be to have that kind of review happen automatically within hours of the event to ensure that all relevant facts can be gathered while they are available and memories are fresh.

Hospitals should have automatic review and root cause analysis processes built in when serious incidents occur - otherwise combinations of unusual circumstances and “isolated” cases of preventable death will continue to happen.

The very least we can do is to ensure that a preventable death prevents another.

One Response to “Confident it was an isolated case”

  1. Am I Blood » Blog Archive » Confident it was an isolated case Says:

    [...] Confident it was an isolated case “The blood bank was not told a cross-match of blood was required until 5.20am.” What is happening here? Is there a communication problem with the blood bank? Not forgetting that they were advised of this same need more than 24 hours … [...]

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