Following an investigation, the Georgetown Public Hospital (GPHC) has confirmed that three young cancer patients succumbed after the improper administration of chemotherapy drugs.
Already devastated by their deaths, the families of Curwayne Edwards, Roshini Seegobin and Sharezer Mendonca must now be given every comfort by the State to enable them to cope with their grievous loss. This is also the appropriate point to ensure that there is adequate malpractice insurance in place for physicians at state institutions to cover disastrous occurrences such as these. “Free” healthcare should not excuse negligent care and the devastating losses that ensue to families.
Notwithstanding its enormous workload, the GPHC has over the years developed a reputation for not seriously addressing a large number of fatal and non-fatal incidents where its personnel have been believed to have been negligent. Families and the general public are often left to endure never-ending or inconclusive probes and the likelihood that no justice is available or remedial action taken. The deaths of three children in a short space of time and as a result of malpractice by likely the same physician made it impossible for these cases to be swept aside.
The sequence of events shows clearly that GPHC has major problems with the quality and supervision of its staff and has not addressed the need for rapid mortality audits which could have been helpful in mitigating the medical trauma suffered by the three children. Curwayne Edwards died on January 14th and three-year-old Roshini Seegobin succumbed on January 18th. All the while, the third child, Sharezer Mendonca, 6, was gravely ill and succumbed on January 24th. The GPHC only announced an investigation of the two deaths on January 20th, a full six days after Curwayne had died and two days after Roshini passed away even though its medical personnel must have detected that all three presented with the same symptoms and that this was a clear case of incorrect administering of potent drugs. It would mean that immediately after Curwayne’s death on January 14, no senior doctor or consultant made that determination from the assessment of the medical charts which should have clearly indicated the manner of the administering of the drug. The post-mortem examination and the mortality audit apparently shed no light on this serious mistake. Roshini was to die four days after Curwayne succumbed and Sharezer held out for a further four days. A discovery at the point of Curwayne’s death of the misemploying of the drug could have had some positive impact on the case management for Roshini and Sharezer and hopefully this is fully addressed in the report by the GPHC and the intervention by PAHO.
It is noteworthy that it took the GPHC more than six weeks to deliver a report on the deaths. That is completely unacceptable for what was a straightforward investigation. So while this investigation and its result are welcome as part of the process of increasing transparency, the GPHC needs to do a better job of assuaging the concerns of families and the public in a timely manner.
Medical malpractice is a deadly serious malady in medical institutions and a problem that needs to be confronted head on when it arises. It appears from the press conference held on Friday by the GPHC that there were staff shortages that led to junior doctors undertaking the tasks of administering the chemotherapeutic agents to the unfortunate children without adequate supervision. That occurrence rises to negligent supervision of these physicians and the hospital’s administration and its medical services department must be held accountable. Particularly since the report presented on Friday was an internal one, there must be a fuller examination of the failings of the hospital in the case management of the three children and a clear statement on the way forward and the accessing of resources to enable better care.
It is now left to be seen how the deaths of these three children will be handled by the Medical Council of Guyana (MCG). For years, members of the public have wondered what disciplinary acts have been taken by the MCG at all against any registered practitioner or whether it even functions. The deaths of these three children is an opportune moment for the MCG to become accountable to the public.
The landmark Medical Practitioners Act of 1991 created the MCG whose functions include ensuring “the maintenance of proper standards established by the Council of professional conduct by medical practitioners and when necessary to take disciplinary action…”
Section 17 of the Act says that any practitioner guilty of professional misconduct or malpractice, shall be subject to disciplinary proceedings. It adds that where it shall appear, or be represented, to the Council that a medical practitioner may be guilty of professional misconduct or malpractice the Council shall afford the practitioner a reasonable opportunity of answering the complaint. Further, where in any proceedings under the section the Council is satisfied that a medical practitioner was convicted of an offence … or is found guilty of professional misconduct or malpractice, it may —(a)censure him; (b)suspend his registration for such period as may be determined by the Council and approved by the Minister; (c) direct the Secretary to remove his name from the register.
While as a semi-autonomous body with a board, the GPHC will be expected to take urgent action to address the gaping deficiencies exposed so far in this probe, the Minister of Public Health must state publicly what her government will do to ensure that the care provided by the premier public health facility is safe and of an acceptable standard in all parts of its operation.
