HMU statement: Concerning a maternal death at Mityana hospital

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• Nansubuga Angel (now deceased) was a 24 year old mother carrying her third pregnancy and was admitted in Mityana hospital on 25th January 2017 and treated for an infection. She improved and symptoms disappeared. Since she was due for delivery, she stayed in the hospital awaiting onset of labor.
• She eventually went into labor and delivered normally a live baby boy on Monday 6th February at 00:15hrs and the baby weighed 3kg.
• Not long afterwards, she started to bleed, the midwives noticed and called the Intern doctor on duty who saw her at 02:40hrs and confirmed that indeed the mother had lost a lot of blood, she wrote her treatment, and called the senior doctor on call. She also planned to take the mother to theatre, but instead she went back to sleep, leaving behind a bleeding mother.
• The senior doctor who was called to attend to what had now become an emergency, did not turn up that whole night.
• Only the midwives and the laboratory staffs who were on duty that night indeed fought and did all they could in an attempt to save the life of this mother.
• The mother continued to bleed until she died at 05:30hrs.
• It was about 3 hours from the time when the doctor was called until when the mother died. The senior doctor failed to attend to this emergency.
• The senior doctor came after daybreak for normal duty and wrote a death certificate for the deceased.
• Following public outcry, a team of HCWs some of whom were involved in the management of this mother sat and made forgeries and alterations in the patient’s file to make it appear as if the senior doctor who was called that night had indeed turned up. HMU finds this highly regrettable and unethical.
• An attempt by senior doctors and other staffs in Mityana hospital to cover up their negligence which cost the life of a mother was further exemplified by the maternal death audit report which deliberately concealed the fact that the senior doctor did not turn up that night to treat this mother. The death audit meeting was attended by the Medical Superintendent, the Head of Department Obstetrics, the senior doctor himself who did not turn up, the midwife in-charge of the maternity ward and the midwives who attended to the mother. Minutes of the meeting and a copy of death audit itself are on record.

FACTS ABOUT BLOOD GIVING SETS AS WELL AS OTHER SUPPLIES:
It was reported in the media that the mother died because of a lack of blood giving set and that this prompted the midwives to demand for Ugsh. 5000/=.
The following are the facts:
• Whereas the hospital claimed that government was not providing supplies and sundries including blood giving sets, it was established that Mityana hospital had never made requisitions for blood giving sets to NMS since this current financial year 2016/17 started and as a result, NMS could not supply what the hospital had not requisitioned for.
• In the last financial year 2015/16 when the hospital was requisitioning for the blood giving sets, NMS was delivering them and the last recorded delivery was on 22nd June 2016. The hospital pharmacist and medical superintendent claimed they did not know about this omission yet they are the ones responsible for preparing and approving such orders. They are some of the very officers who were claiming that government failed to provide blood giving sets!
• On Friday 10th February 2017 after the HMU audit revealed this fact about blood giving sets is when the hospital pharmacist through the medical superintendent wrote to NMS requisitioning for the item. A copy of the letter is on record.
• HMU did not establish and cannot confirm whether any midwife asked for UgSh. 5000/= to buy a blood giving set and does not accuse any HCW for such.
Facts about other supplies in the hospital.
· It was also confirmed that all pregnant mothers on the ward who needed a cesarean section were buying all the supplies needed for theatre. These included IV cannulas (Green G18), Fluid giving sets, Syringes (10mls and 5mls), Sutures/Stitches, Folley Catheters, Gauze, Jik and others.
· None of the items above were completely out of stock in the medicines store. The store had over 300 cannulas, over 75 giving sets and other supplies.
· HMU recognizes the fact that not all supplies may be available to cater for all the patients at all times but that does not justify the decisions by HCWs to deny patients needing emergency treatment such as mothers for cesarean section supplies which are available in the hospital even when they are in small quantities.

HMU response to Uganda Medical Association (UMA) allegations:
• Whereas HMU responded to this matter and started investigations within 2 days to establish facts, UMA only showed up 9 days later when investigations were in an advanced stage.
• HMU together with the District chairman Mityana and the deputy RDC Mityana furnished members of the UMA led by Dr. Ekwaro Obuku with details of what happened but they deliberately chose to ignore these and took to social media to disseminate inaccurate information and insults about HMU, its appointing authority and its staff.
• HMU condemns such hypocrisy exhibited by UMA led by Dr. Ekwaro Obuku, and their decision to deliberately distort facts and malign Health Monitoring Unit while making statements and comments not founded on facts on ground when they had ample time to investigate and establish facts..
• HMU condemns the insensitivity Dr. Ekwaro Obuku and UMA exhibited towards the bereaved family and the now orphaned three children one of whom is a newborn baby whose survival chances are now greatly compromised by the absence of his mother.

SUMMARY:
• HMU condemns the refusal of the senior doctor to respond when called upon to save a life.
• HMU condemns the deliberate attempt by the senior staffs of Mityana hospital to conceal information by making forgeries in the patient’s file after the patient had died.
• HMU condemns the physical attacks to HCWs by members of the public
• HMU commiserates with the family of late Angel Nansubuga and prays that the Almighty Lord comforts and strengthens them in this mourning period.
• HMU appreciates all HCWs in all cadres who are diligently serving the Uganda people despite the several challenges.
• HMU appreciates the nurses and midwives, laboratory staffs and the others of Mityana hospital who did what they could in an attempt to save the life of Nansubuga Angel.
• HMU wishes to thank Mityana police and local authorities who responded swiftly on Monday 6th February and dissipated an attack that was launched on the HCWs of Mityana general hospital
• HMU does not and will not indiscriminately arrest HCWs without sound reasons.
• HMU through its attached police CID department is mandated to investigate cases in the health sector and sometimes part of those investigation involve arresting suspects but HMU does not delight in arresting and incarcerating HCWs.
• HMU will continue to execute its mandate and work with all stakeholders to ensure that quality health care is delivered to the people of Uganda indiscriminately.
• HMU calls upon all doctors and other HCWs not to neglect their duty towards innocent patients which may lead to loss of lives despite the many challenges they face in their profession.

Issued by Dr.Elijah Semaganda,

HEALTH MONITORING UNIT (HMU), STATE HOUSE

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