Why six premature babies died at government hospital

2010-07-22 09:19

These are the key findings and recommendations of the investigating

team into the deaths of babies at Charlotte Maxeke Johannesburg Academic

Hospital (formerly Johannesburg General).

The panel included the head of neonatology at Chris Hani

Baragwanath hospital, Sithembiso Velaphi, as well as members of the Retired

Nurses Forum.

According to the panel’s findings:

  • In all six babies the cause of death appears to be related to a

    highly virulent (extremely infectious or poisonous) outbreak of gastroenteritis

    (diarrhoea and vomiting) in the premature baby unit.

  • All the babies were high risk cases with a birth weight of less

    than 1.5kg.

  • The general level of medical care was good. The onset and

    progression of disease from well to death was extremely rapid. No individual

    cases seemed to show any specific medial negligence.


The investigation found that overcrowding was a major contributory

factor. Overcrowding meant that:

  • There was less space between the baby cribs, which increased the

    rate of infection.

  • There was not enough staff in relation to the norms of safe care,

    which meant that the more babies an individual nurse cared for, the higher the

    risk of mistakes.

  • More outside visitors would enter into the available space.

The investigation also found the following irregularities regarding

the resources in the neonatal ward:

  • Lack of routine supplies such as roller towels and antiseptic

    spray, leading to inadequate hand-washing.

  • Not enough routine equipment such as thermometers, dextrometers

    and oximeters.

  • Lack of locker facilities and change rooms for staff and parents

    meant that parents’ bags and jackets would be placed on the shelves.


The Gauteng Department of Health and Social Development has said

that in order to “address these factors”, from July 1 all hospital Chief

Executive Officers have to procure infection control equipment (roller towels,

thermometers, etc) directly.

Previously, the CEOs would have had to go through the Gauteng

Shared Service Centre. The department hopes this will make obtaining infection

control equipment quick and save lives.

The panel recommended that:

  • A Neonatal Advisory Task team comprising of two to three

    neonatologists and two to three neonatal nurses be established to advise the

    health department on issues of neonatal care in the province.



The department says that it has employed 30 retired nurses to go

around the province’s health facilities to strengthen infection control

measures.


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