“The babies were infected with norovirus, a relatively common gastro-intestinal virus that is spread by contaminated hands, water or food. In all the six babies, the cause of death appears to be related to a highly virulent outbreak of gastroenteritis in the premature baby unit. Number 2: All babies were high-risk cases with a birth weight of less than 1500g, although most seemed to be progressing well before the outbreak”, Gauteng Health and Social Development MEC, Qedani Mahlangu declared at a media briefing earlier this week.
The investigation exonerated the nurses in ward 177 at Charlotte Maxeke of any wrong-doing.
“The response of the hospital to the outbreak of vomiting and diarrhea among the babies on May 16 was found to have been adequate. No specific acts of negligence in relation to the care or treatment of individual patients were identified in all of these. The general level of medical care was good. The onset and progression of disease from well to death was extremely rapid, making it difficult for it to be managed properly. No individual cases seemed to show any specific negligent medical care”, Mahlangu said.
At pains to explain that there was no negligence on the part of nurses, she blamed insufficient health systems and took responsibility for the deaths of the six babies, saying:
“If a nurse is over-loaded with work, looking after seven babies instead of one or two babies, how do you hold that individual responsible for the death of a baby? I’ll be the first to say someone’s head must roll or I’ll be the first to fire somebody. But in this instance there is no basis to fire any human being or to say any human being must be subjected to disciplinary procedures because there is no clear evidence of such. And the fact that the nurses are over-loaded… it’s my problem and I must deal with it”.
While the Health MEC stood her ground, arguing that health personnel were not at fault, she spared no words in fingering health systems as a major factor in the babies’ deaths. Top of the list was over-crowding.
“Issues that were identified relating to the over-crowding, in particular, was that there was less space between baby cribs or incubators, which increases the risk of infection. The space between one incubator to the next was very limited and as a result, it’s easy for infection to pass from one patient to the other. Number 2 - insufficient staff relative to the norms. This ward is supposed to be defined as a hi-care… It’s supposed to be one nurse to two babies and at the time it was seven babies to one nurse.
These norms were insufficient at the time when this thing happened, so that makes it difficult… when one baby gets too sick for a nurse to be attending to all of them at once because of the norm of 1: 2.
And more babies to be cared for by each nurse, which increases the risk of mistakes in the standard of care. Sometimes they prioritise those babies who are too sick and services are compromised in the process.
More mothers and outside visitors enter into the available space and there is no dedicated space that is designated for mothers when they come and visit their babies. Remember we spoke about the virus that would have come from outside and this is a point that this over-crowding is causing as a result… that the mothers, including the fathers when they come, and sometimes the family members, and it’s important to note that that is an issue we need to improve going forward”, said Mahlangu.
She said the investigation also highlighted a number of deficiencies regarding the hospital and resources.
“ Lack of routine supplies such as roller towels or antiseptic sprays… Without towels, adequate hand washing cannot take place. You’ve got to observe this thing of washing hands from one patient to the other, but also when you go in and out of the ward. At the time these things were not happening… Insufficient routine equipment such as thermometers, lack of locker facilities and change rooms for the parents and staff, which result in parents’ jackets and bags being placed on shelves within the ward. The virus may have been brought by the parents or people coming from outside”, said the MEC.
As an immediate measure, the Health Department in the province has decided that all hospital Chief Executive Officers will procure infection control equipment directly without going through the Gauteng Shared Service Centre. This will make the procurement of infection control equipment quick and will save lives. But it is harder to implement longer-term solutions such as employing more nurses. Until this happens, over-crowding and sub-standard care will continue to plague the health system.
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