Hospital owner in the dock

What you need to know:

  • Dr Tamale Ssali, the proprietor of the hospital and the anaesthetist during the operation were charged before the Chief Magistrate, Buganda Road Court with one count of causing death by a rash or negligent act. 

On October 14 2010, Ms Ayiru Mercy died at the Women’s Hospital International Bukoto, in Kampala during a botched operation to remove a solitary fibroid from her uterus using laparoscopic surgery. 

Dr Tamale Ssali, the proprietor of the hospital and the anaesthetist during the operation were charged before the Chief Magistrate, Buganda Road Court with one count of causing death by a rash or negligent act. 
The State was duty bound to prove that Dr Ssali and the anaesthetist acting together did a rash and negligent act that caused the death of Ayiru. 

In any criminal trial, an accused person is presumed innocent until proven or pleads guilty. The burden of proof rests entirely with the prosecution throughout the trial and it is the right of the accused person to decline to put up a defense. 
In any trial, a court of law will strictly rely on the evidence adduced before it, no less and no more. However, the interpretation of the evidence is the privilege of the court.

Testimony 
The first witness who testified for the State against Dr Ssali was the elder sister of the deceased who had gone with her to the hospital the morning of the operation. She told court that she stayed in the waiting room while her sister was wheeled into the operating theatre. 
After some time, Dr Ssali came out of the theatre and asked her if her sister was a drug addict, an alcoholic or whether she had a mental ailment. 

Dr Ssali did not offer her adequate explanation why he was asking these questions but told her “to prepare for anything”.  She was eventually informed that her sister had died and she immediately accused the medical team that handled her sister of having killed her.

Post-mortem 
She demanded a post-mortem examination to be carried out on the body of her sister.  The body of Ayiru was brought to Mulago Hospital and two pathologists were asked to carry out the post-mortem examination. Dr Ssali’s hospital made a formal request for the post-mortem and indicated in the request note that the patient’s heart had slowed significantly as soon as the operation started and eventually stopped.
 
The pathologists called one of the doctors on the medical team that had operated on the deceased to be present during the post-mortem examination but the doctor declined. 
The pathologists also needed more information on what exactly happened in the course of the operation. This information was not availed to them.

Findings 
During the post-mortem examination, the pathologists noted that there was a small incision in the abdomen of the deceased and the tissue overlying the intestines was bruised. The uterus was intact and contained a solitary fibroid. The most significant finding was that of half a litre of blood in the stomach. The pathologists, at the time of the post-mortem, did not have an explanation for this blood. 

It was, therefore, clear that the patient died at the beginning of the operation; not much surgery had been done as the fibroid which was to be removed was intact.  The slowing of the heart and bruising of the tissue overlying the intestines meant that the patient had received inadequate anaesthesia. 

Conclusion 
The pathologists concluded that “death was consistent with intra-operative neurogenic cardiac arrest and associated acute gastritis”.  Court apparently found these terms too difficult to comprehend.

One of the pathologists was requested to make a police statement when the case was reported to police. The statement was to substantiate further on the findings contained in the post-mortem report and in essence to give more information on the cause of death. The pathologist was to later testify as a State witness.

The police investigated the death of Ayiru as a complaint had been lodged with them in respect of this death. 
The police subsequently interviewed and got a written statement from Dr Parker Rafique, the lead surgeon who had operated on Ayiru. 

In the statement, Dr Parker intimated that the tube which should have supplied oxygen and anaesthesia to the patient had been wrongly inserted in her oesophagus instead of the trachea. In hindsight Dr Parker, would have been a vital witness for the prosecution.
The pathologist who testified told court that the effects of the wrong intubation were that;

•The patient was not receiving adequate anesthesia and oxygen.
•The anaesthesia was going into the stomach which caused irritation and distention of the stomach and therefore the bleeding.

The pathologist told court that when a patient is poorly anaesthetised and certain sensitive parts of the body such as the tissue overlying the intestines are touched, the nerves slow the beating of the heart and eventually cause it to stop beating all together. 

A senior anaesthesiologist, who had inspected the theatre in the hospital in 2011, testified as an expert witness for the State. According to the expert, the theatre was very poorly equipped for laparoscopic surgery. 

In addition, the theatre had a manual ventilator instead of an automatic one and the manual ventilator had several challenges. And the monitor in the theatre did not have a provision for detecting the electrical activity of the heart. The expert’s formal report of the inspection was tendered as part of the prosecution’s evidence.

The State presented two more witnesses; a member of the Uganda Medical and Dental Practitioners Council and the investigating officer.