Investigation reveals failures behind fatal baby hospital incident

The Health Ombud on March 23 released a report into the death of a baby at Netcare Femina Hospital in Pretoria.

The report found that the incident in 2023 resulted from failures in patient care and other broader systemic issues, highlighting the need for accountability in the healthcare sector.

Netcare Femina Hospital has expressed grief over the incident.

“We share deeply in the family’s grief over the loss of their precious son. No words can adequately express our sorrow and regret for their profound loss,” said Tau Kgomongwe, general manager of Netcare Femina Hospital.

The incident occurred on May 29, 2023, after adrenaline was administered intravenously instead of via nebulisation, a fatal clinical error.

Health Ombud Professor Taole Mokoena stated in the report that, “While the investigation could not substantiate the allegation that incorrect medication was given, it established that the intravenous route of administration of the medication written on the script was an error and led to a fatal outcome.”

Findings in the report also uncovered systemic failures, including poor communication among healthcare professionals, outdated procedures, and weak safety protocols.

“This tragic incident highlights systemic failures within clinical care pathways and the importance of good leadership and stewardship, continuous mentoring and in-service training to keep abreast with developments and innovations within the NICU [Neonatal Intensive Care Unit],” the report added.

In addition, the hospital was found to have committed a legal lapse by failing to refer the death for a forensic post-mortem, a requirement when a medical procedure may have contributed to a patient’s death. Other risks identified included weak shift handovers, staff sharing passwords, and poor electronic system controls.

The ombud recommended several actions, including staff referrals, system improvements, enhanced training, and stronger oversight mechanisms.

In response, the hospital said it welcomed the findings and emphasised its commitment to transparency and improvement.

“Independent review processes such as this strengthen our healthcare system by providing clarity for families and healthcare professionals while ensuring the highest standards of patient care are upheld,” said Dr Erich Bock, managing director of Netcare’s hospital division.

Dr Bock said the electronic records system was designed to enhance patient safety, including preventing medication errors.

“Since its implementation in 2019 and its gradual rollout across our operations countrywide, the system has evolved significantly, strengthening its role as a robust patient safety tool,” he added.

The hospital said it has adopted the Ombud’s recommendations and is implementing them within set timelines.

Measures include mandatory forensic post-mortems in cases involving possible medication errors, annual reviews of medication protocols, improved shift handover monitoring with unit managers present, and system upgrades to notify users of updates to the electronic medical records system.

“Following the Health Ombud’s findings, Netcare has proactively embraced the recommendations and is implementing them according to the established timelines,” said Dr Bock.

Netcare reaffirmed its commitment to accountability and patient care.

“Every member of our team, from nursing staff to doctors and management, is committed to honouring the memory of the baby by ensuring our systems and processes protect every patient in our care, especially the most vulnerable among us,” concluded Dr Bock.

WATCH:

Do you have more information about the story?

Please send us an email to bennittb@rekord.co.za or phone us on 083 625 4114.

For free breaking and community news, visit Rekord’s websites: Rekord East

For more news and interesting articles, like Rekord on Facebook, follow us on Twitter or Instagram or TikTok or WhatsApp Channel