Deaths that occur during a surgical operation should ideally be investigated comprehensively and audited or reviewed.
One of the purposes of such an audit or review is to establish what went wrong and correct such wrongs to prevent what would have been similar deaths in future.
One such death was that of Ms Ayiru Mercy that occurred on October 14 2010, at Dr Tamale Sali’s Women’s Hospital International and Fertility Centre. The deceased died during a botched operation to remove a solitary uterine fibroid using laparoscopic surgery.
Professional bodies who often spearhead such inquiries need, however, to set ground rules to guide them.
The first of these rules is to define the wrongs and rights and adopt the appropriate standards to be used and the penalties prescribed.
Professional bodies inquiring into such deaths must be clear on what constitutes medical negligence or malpractice or any other wrong and these should be written down and availed to the medical, dental or health practitioners.
The standards used in civil law differ from that in criminal law and these are different from the standards used in medico-legal inquiries by a professional bodies. In criminal law, there can be no crime where there is no law.
Necessity of the operation
One of the cardinal questions asked during a medico-legal investigation of a surgical operation is whether the operation was really necessary, that is, whether there was a medical or surgical reason for doing the operation.
It is no defense to say that the patient requested for the operation. In hindsight one would ask what would happen to the patient if the operation had not been carried out.
There is no doubt that Ms Ayiru would not have died but for the operation. Fibroids by themselves rarely cause death.
The reason advanced for the operation was infertility but this was not medically proven as the deceased was not married and had not investigated for infertility.
Another line of inquiry is usually whether the patient consented to the operation and evidence that the patient was provided with appropriate information to make the choice and whether other treatment options were availed to the patient.
The consent for a major operation as in this case should have been written and witnessed.
The hospital in this case told the Inquiry that the patient consented to the operation but did not provide the appropriate proof.
It was not clear what information the patient was provided with in respect of fibroids, the various options of managing fibroids, the side-effects of the various interventions, complications of surgery and various choices of anaesthesia available to her.
Preparing a patient for surgery
How a patient is prepared for surgery is important in the investigation of a death during a surgical operation.
In this particular case the patient was called by the hospital to come for admission on the day of the operation. Evidence before the inquiry was to the effect that the patient appeared apprehensive and had an elevated blood pressure.
The anaesthetist told the Inquiry that under the circumstances, the surgery should have been cancelled.
Patient preparation involves review by the surgeon and anaesthetist and these should, without doubt, be documented. No such notes were availed to the investigating team.
The competency of the operating team and the facility is an area scrutinised during a medico-legal inquiry.
Competency is judged by the standard of care offered to the patient, and the standard is whether the patient was offered reasonable care.
According to Dr Tamale Sali , the surgeon he hired to carry out the operation is the forefather of laparoscopic surgery in East Africa. Evidence of this should, however, have been brought forth.
And the competency of the anaesthetist should also have been investigated, that is, whether he was adequately trained and experienced enough to give anaesthesia during laparoscopic surgery, and how prepared he was to resuscitate a patient in case of any emergencies.
It was established that her death was an anesthetic accident. One anaesthesiologist who inspected the theatre however noted that that particular theatre was ill-prepared for surgical operations.
It is of paramount importance that the medical, dental and other health practitioners are duly registered and have practicing certificates, as required by the laws of the country.
This is not only to protect patients from quacks but to ensure an orderly and lawful practice of medicine and surgery. The chief surgeon in this case, Dr. Rafique Parkar was not registered to practice medicine in Uganda.
Health facilities are registered to offer a variety of services according to their grading.
It is prudent for the supervising body to provide specific licenses for specialised operations to specific units that meet particular criteria.
And whether or not the facility was granted a license for such a specialised surgery did not clearly come out during the inquiry.
Circumstances of the death
The investigations of the circumstances of or the events preceding a death are vital in a death inquiry.
This information will determine whether the death could or could not have been avoided. A postmortem examination will independently verify the circumstances as well as the cause of the death.
In this particular case a witness statement attributed the death to wrong intubation and subsequent suffocation of the patient. The postmortem examination confirmed the statement.
By Dr Sylvester Onzivua