KNH doctors who opened the brain of the wrong patient are not to blame, the Kenya Medical Practitioners and Dentists Board has said.
The board appointed a
Plenary Inquiry Committee to look into the matter that was first reported on March 2.
The committee reported on Sunday that the competence of doctors
Hudson Ng’ang’a and Mose Moraa could not be questioned as their teams reviewed documents presented to them in the theatre.
The team also said procedures.
In its lengthy statement, however, the committee said it was clear that the surgery was performed on the wrong patient.
THE FINDINGS
1. The Committee considered the evidence adduced before it and also perused the documents presented before it and finds that the competency of the Dr. Hudson Ng’ang’a Kamau, who undertook the surgery of the patient, assisted by Dr. Mose Moraa, could not be questioned as his Team reviewed the documents presented to them in theatre appropriately and thereafter undertook the proper procedure that would have been expected in a proper scenario. However, it is not in dispute that the procedure was undertaken on the wrong patient for reasons set out hereunder.
2. Further, the Committee finds that the capability of one nurse, Mary Wahome, to work in specific units of the Hospital needs to be considered by her Regulator, the Nursing Council of Kenya, as she testified that she had been unwell for several months after being involved in an accident, and had not recovered fully.
During the inquiry she requested to be allowed to give her evidence while seated stating that she was not able to stand for a long period of time. It was her evidence that the work load at the Hospital was much and on the night of 19th February 2018 they had 61 patients assigned to only three (3) nurses.
The Committee finds that the appropriate Regulator should consider whether the said nurse is fit to practice under such an environment. The said nurse also admitted being aware that the patient was in a confused state but on being requested to deliver one, John Mbugua Nderitu, to the trauma theatre she went to Room 2 with a porter and shouted his names and she then prepared and labelled the “responsive patient” before taking him to theatre.
It is the finding of the Committee that the said acts also contributed to the unfortunate mishap as the “responsive patient”, who was in a confused state due to head injuries, was labelled as John Mbugua Nderitu and taken to the surgical Team in theatre with all documents for John Mbugua Nderitu.
3. The Committee further finds that the evidence on record shows that Kenyatta National Hospital had Standard Operating Procedures (“SOP’s”) for the various processes but there was a challenge on their implementation, monitoring and evaluation. Dr. Peter Masinde, the Acting Director of Clinical Services at the Kenyatta National Hospital, was very candid in his evidence as he admitted that some of the SOP’s within Kenyatta National Hospital were just there on paper but had never been used as would be expected.
He admitted that the Medical Advisory Committee (“MAC”) of the Hospital existed only on paper and in his view it was dormant which contradicted the evidence of Dr. Ben Githae and Ms. Lily Koros. Dr. Githae had testified that the said Committee existed though it only addressed disciplinary issues whereas Dr. Masinde stated that he may need to
go the their archives to get minutes of the said Committee, if they ever existed. The evidence on this limb was very worrying as there was clear contradiction by very senior staff members of Kenyatta National Hospital on a very crucial aspect. The Committee considered the global purpose and practice of MAC’s being an important Committee of medical staff that ensures clinical services, procedures or interventions are provided by competent health care professionals in an appropriate and timely manner.
4. The committee also finds that there are glaring gaps on the admission process at the Kenyatta National Hospital. It was noted that the neurosurgery patients were spread in different wards within the facility and as a consequence being a potential risk to proper management and follow-up of the patients. A consultant at the Hospital, Dr. Mwangi Gichuru, confirmed that they were unable to review all their neurosurgery patients on a daily basis and it was clear that the manner such patients were admitted was a contributory factor.
5. The committee further finds that there was a challenge on the chain of command and communication between the Hospital and the University of Nairobi, School of Medicine.
The evidence on record was that the duty rota was prepared and approved by Prof. Mwangombe for teaching purposes whereas it may not work optimally for the Hospital. The witnesses also confirmed that the working relationship of the two institutions was affecting their operations and under the current structure of calls the Residents and University Lecturers appear more prominent as compared to the specialists directly employed by Kenyatta National Hospital.
It was noted that the management of the Hospital purported to withdraw admission rights of a Registrar and it is doubtful whether the Registrar had admission rights at the Hospital as he is assumed to have practising rights by virtue of being a post-graduate students of the University of Nairobi. The Committee notes that the admission rights are for doctors who are duly registered and recognised in their various specialities by the Medical Practitioners and Dentists Board. The Committee further noted that the practising rights to Registrars and lecturers from the University is not given in writing but it’s only assumed by virtue of the fact the KNH is a teaching Hospital for the School of Medicine of the University of Nairobi.
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John Mbugua, the patient who was to undergo a brain surgery at KNH, before the National Assembly Health committee, March 14, 2018. /HEZRON NJOROGE
6.
The Committee reviewed the patients files submitted to the Board and noted that there was poor documentation by different cadres involved in the management of the patient. The nurse’s cardex had poor records and missed the times when certain interventions were undertaken. Most of the witnesses from the Hospital stated in their evidence that there was a pre-operative checklist but this was contradicted by the Acting Director for Clinical Services, Dr. Masinde, who candidly confirmed that there was no such checklist.
Both Prof. Mwangombe and Dr. Mwangi testified that they reviewed the patient herein and made notes but a review of the patient’s file that was presented to the Board showed no notes on their interventions. Further, the nurses testified that there was hand over of the patients on the evening of 19th February 2018 but there were no records to support such evidence. Nurse Gideon Mwangi confirmed that he reported for the night shift on the evening of 19th February 2018 when nurse, Rita Akinyi, did a verbal hand over of 61 patients as his other colleagues had not reported to work and he recorded the same in the nurses report book. He stated that he saw the patients who were in the ward through a window and he could not clearly point them out as the wards were crowded.
It is doubtful whether three (3) nurses could be able to manage 61 patients and do proper documentation more so in the manner they were working. The Committee also noted that the anaesthetist was unable to sign the consent due to the manner the rota is prepared. The Committee was guided by the provision of Chapter IV of the Code of Professional Conduct and Discipline, 6th Edition, at page 31 which states, inter alia, that:-
“Practitioners and Institutions shall create, maintain, store and retain complete records and date relating to their professional work and patients in order to;-
(e) Facilitate subsequent professional intervention or inquiry”
7. The Committee further finds that at the material time Kenyatta National Hospital appears to have had challenges in the supply of resources including patients’ identification materials for the user Departments. As a consequence thereof the nurses were at the material time had improvised and were using strappings which may have contributed to the mix up of patients. It was noted that Dr. Githae testified that at the time the Hospital had identification labels in its stores, though of poor quality, and he was unable to explain why the same had not been supplied to the user Departments.
8. In view of the above findings the Committee holds that a surgical procedure was done on a wrong patient as a result of systemic lapses at the Kenyatta National Hospital thus affecting the functioning of the different professional cadres who were working at Hospital at the material time.
The said Institution and the different professional cadres are regulated by different Regulatory Bodies and that is the wisdom used to incorporate the Nursing Council of Kenya and the Clinical Officers Council in the inquiry herein. The mandate and powers of the Preliminary Inquiry Committee are sanctioned by Section 20 of the Medical Practitioners and Dentists Act and Rule 4, and all other enabling provisions, of the Medical Practitioners and Dentists (Disciplinary Proceedings) (Procedure) Rules which gives the Medical Practitioners and Dentists Board and this Committee powers to sanction or make appropriate orders against or in respect to persons regulated by the Board.
In the same limb this Committee has no powers in Law to sanction or make any orders against or with respect to professionals who are licenced and regulated by other Regulatory Bodies.
The Committee having carefully considered the applicable Law and the statutory mandate of the Preliminary Inquiry Committee under the Medical Practitioners and Dentists Act, the findings made herein above and the role played by different professionals leading to the surgical mix-up on patients, John Mbugua Nderitu and Samuel Kimani Wachira, at the Kenyatta National Hospital, consequently holds that this Committee has no powers in Law to sanction other professionals save to those licenced and regulated by the Medical Practitioners and Dentists Board.
In that regard the Committee holds that the matter under inquiry has raised serious issues that are of great public interest and hence the need for appropriate inquiries by the respective Regulatory Bodies to enable them make the necessary findings and
recommendations or render sanctions as set out by the applicable Statutes.
Kenyatta National Hospital medical personnel Mary Wahome and Malakai Odhiambo before the National Assembly Healthy committee over a brain surgery on the wrong patient, March 14, 2018. /HEZRON NJOROGE
ORDERS BY THE COMMITTEE
i. The Medical Practitioners and Dentists Board do constitute a Professional Conduct Committee under the provisions of Rule 4 A of the Medical Practitioners and Dentists (Disciplinary Proceedings) (Procedure) Rules within the next three (3) days to undertake an inquiry on the role played by Kenyatta National Hospital and the doctors involved in the treatment and management of the two patients, John Mbugua Nderitu and Samuel Kimani Wachira.
ii. The Professional Conduct Committee to be constituted under (1) above, shall convene its sitting in Nairobi within the next Fourteen (14) days.
iii. The Medical Practitioners and Dentists Board shall forward a copy of this decision to the Nursing Council of Kenya within the next three (3) days to enable the said Council initiate an inquiry under Section 18B of the Nurses Act on the role played by nurses in the treatment and management of the two patients, John Mbugua Nderitu and Samuel Kimani Wachira, leading to the mix up and the mistaken surgery. The said inquiry shall be commenced within the next fourteen (14) days and the Council shall take appropriate action under the circumstances of the case.
iiii. The Medical Practitioners and Dentists Board shall forward a copy of this decision to the Clinical Officers Council of Kenya within the next three (3) days to enable the said Council to initiate an inquiry on the role played by Clinical Officers in the treatment and management of the two patients, John Mbugua Nderitu and Samuel Kimani Wachira, leading to the mix up and the mistaken surgery. The said inquiry shall be commenced within the next fourteen (14) days and the Council shall take appropriate action under the circumstances of the case.
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