Negligence at Mama Lucy Kibaki Hospital led to woman's death – Senate report
Robert Omondi, Maureen Anyango’s widower, breaks down when he appeared before the Senate Health committee in Nairobi on November 1, 2022.
Maureen Anyango died at Mama Lucy Kibaki Hospital as a result of medical negligence, a report has revealed.
According to the report, Maureen waited for eight hours from admission to the hospital until she was taken to the theatre for an emergency caesarean section.
The Senate Health committee’s report released yesterday revealed that the death could have been avoided if proper procedures had been followed at the hospital from the time of her admission to her subsequent transfer to Kiambu Level Five Hospital.
On admission on September 5, 2022, the committee found that Maureen did not receive the necessary care given that she was a first-time mother carrying twins.
“The committee noted that on admission, a diagnosis of twin pregnancy in a primigravida (first pregnancy), in active labour, with malpresentation, should have automatically triggered a decision to perform an emergency caesarean section. However, emergency caesarean section was repeatedly delayed,” the report states.
According to the hospital’s gynaecologist, the decision to delay Maureen’s emergency caesarean was to allow for the stabilisation of her pre-eclampsia.
However, this assertion was refuted by the committee following review of evidence obtained from relevant health authorities, which showed that tests for pre-eclampsia had not been carried out and that there were inconsistencies in the documentation of vital signs from the time she was admitted. The hospital also failed to provide evidence that the patient’s vital signs that they had recorded were accurate.
It was clear from the evidence of many that between 10.05am and 1.20pm, Maureen had been bleeding, and despite the husband’s repeated attempts to get help from a ward nurse, he was ignored. By 1.20pm, she was already in shock from blood loss and her blood pressure had dropped. When the hospital realised that she was bleeding, she was transferred to the theatre for examination under general anaesthesia. The anaesthesia did not reverse, so she was kept on mechanical ventilation.
At 5pm, a decision was made to refer her to intensive care and she was transferred to Kiambu Level 5 Hospital at 1.20am on September 7, 2022. After the decision to transfer was made, Maureen was kept waiting again.
“There was an unwarranted delay of about eight hours in the transfer of the deceased. At least two hours were lost in transit, with evidence showing that the ambulance took almost two hours to arrive at KL5H from MLKH, despite the two hospitals being approximately 20km apart,” the Senate report states.
While in the ambulance, the nurses were forced to bag her with room air because the cylinder they were using had run out of oxygen. They were unable to open a second one due to lack of a wrench. She suffered hypoxia as a result of using room air, arriving at the Kiambu hospital unconscious and in critical condition. She succumbed six hours later at 7am.
The committee warned hospitals against playing with people’s lives and attempting to cover up key details.
“There was a falsified reason as to why the emergency caesarean section was delayed by approximately eight hours and inconsistent timings provided by MLKH ...” the report states.
The committee found that Mama Lucy Kibaki Hospital does not meet the criteria to be classified as a Level Five hospital. It recommends that the facility be investigated by the relevant health authorities. Further, it wants Dr Lazarus Kumba, the hospital’s obstetrician/gynaecologist be investigated by the Kenya Medical Practitioners and Dentists Council for giving false evidence.
It also recommends that the Kenyatta University Teaching and Referral Hospital Chief Executive Officer and board be held liable for requiring a down payment of Sh200,000 as a pre-condition for admitting Maureen to intensive care in contravention of Article 43(2) of the constitution.
The Health ministry, Nairobi City County government, Council of Governors, Kenya Bureau of Standards and police are to implement the report’s recommendations within three months of receipt.
