These are my thoughts on the recent incident where a destructive operation (decapitation) had to be performed due to obstructed labor in a patient admitted in IGMH. According to statement from IGMH, the fetal decapitation had to be performed because there was no other alternative. The IGMH statement did not explain why a cesarian section had to be done, because destructive operations are resorted to so that a delivery by cesarian section can be avoided. Considering the fact that the patient was under their care for over 2 weeks, there are a number of issues that are not clear; the basis for the decision to conduct a normal vaginal delivery in the face of the high risk factors, the grounds for the decision to carry out a cesarian section after the decapitation and how much information was provided during the consent process. Furthermore there are the issues with the Maldives Police Service (MPS) and the Human Rights Commission of the Maldives (HRCM) investigating the incident when the investigation will be carried out by IGMH and the Quality Assurance and Improvement Division (QAID) of the Ministry of Health and Family (MoHF).
Based on previous experience, I can foresee a lengthy and troubled battle ahead between these institutions, because in most such incidents a patient party would file a complaint at the MoHF, the MPS and the HRCM. The MPS and HRCM would then write to the MoHF to investigate.
As with other incidents where deaths have occurred in the healthcare settings, and where complaints are lodged, the Maldives Police Service’s investigation would be conducted by the Serious and Organized Crime Unit. I find this highly inappropriate and even reprehensible, specially when an investigating officer told me on two occasions that there are doctors who kill their patients. Perhaps he was referring to some incidents abroad, but deaths in the healthcare settings should not be investigated by the Serious and Organized Crime Unit.
The HRCM’s role in such investigations remains unclear. We are not party to any treaties similar to those as the European Convention on the Human Rights which enforce the states to protect the rights in the Universal Declaration of Human Rights such as right to life. We are all too familiar with fuss caused by HRCM during their investigation into the ‘Jaariya’ case some time ago when patient confidentiality was not taken into consideration. On another occasion last year, during their investigation of a death of a child, they were threatening the use of their legal power to obtain confidential records from the QAID. While it is true that the HRCM has more legal power than the MoHF, without a clear objective framework as to how the HRCM’s investigation would benefit the public or even protect the human rights, their involvement is more of an added complication.
The role of MoHF and QAID are obvious. The QAID is tasked with investigating any complaints made by the public about the healthcare setting, ranging from adverse incidents to deaths in the healthcare setting. The Review Unit oversees the work of the Review Committee, the Professional Standards and Ethics Committee, The National Patient Safety Committee and the Maternal Death Review Committee. Most investigations into adverse events occur irrespective of whether a complaint is made or not. Of course the public is not aware of this and that is the reason why the same complaint is lodged at different institutions.
Patients complaints are an important source of feedback for the improvement of healthcare. They provide information as to where the weaknesses in the system lies. An avenue to complain lets the patients know that the service providers are concerned when things go wrong, and that measures will be taken by the health care providers to prevent future such occurrences. It provides an opportunity for the providers to give an explanation and even an apology. My efforts to publicize the complaints process by making a comprehensive complaints system was received with annoyance and irritation by the doctors.
This brings me to the role of the doctors as the key component in the whole process. Even though the investigations would be carried out ‘independently’ by the three organizations, they all have to rely on the evidence given by the doctors. However, the readiness of the doctors to provide such evidence is limited. There is much reluctance on their part for reasons that remain beyond my comprehension. Any investigation into the quality of care is viewed with skepticism and as a threat to their professional autonomy. There are no efforts to standardize treatment, conduct clinical audits, and in the absence of a learning environment, there is little drive for continuous professional development programs. They should be ready to admit that mistakes and errors do happen. Studies into the amount of adverse incidents occurring at IGMH need to be carried out. Unless sincere efforts to reform come from them, the quality of health care will not improve.
The ongoing process of investigation into this incident would yet again bring out the difficulties and deficiencies in the system. QAID will be again in the difficult position to arrange meetings because of the lack of doctors to conduct a review. Once a meeting is convened, after several cancellations and delays, the facts of the case would be contested, as would the justifications for the decision to undertake the decapitation. Questions of fault and responsibility would depend on the doctor’s views as there are no standards to judge the incident against. When a report is finally drawn up, the QAID will not share it with the MPS and HRCM stating that their investigation is for the purpose of improving quality, and not finding fault, and partly because the doctors would condition their participation in the review process on non-disclosure. This is specially so if there are obvious problems with the actions of doctors. The MPS and HRCM then would threaten to obtain the report by going to the court. It was only a few weeks ago a controversial judgement was passed by the courts in order to make MoHF accountable.
What is to be noted here is that the process will not be rectified unless legislation is drawn up. Health care needs to be regulated and legislation is necessary in all aspects, from the services to the professionals.The People’s Majlis should stop fooling around and work to pass key legislations that are relevant to the people such as those that have already been submitted by the MoHF.
It is incidents such as these which has forced health care in other countries to be transformed into a more patient-centered approach, and to make healthcare providers more accountable, after years of giving unquestioned acceptance, or even tolerance, to the actions of doctors. I once asked one of the most prominent doctors in the Maldives why, we as doctors, should not take the initiative and put in place regulations and make efforts to improve the quality of care before things get out of hand. He replied that it is the role of patients to drive such change.
It is my hope that the patients, and the public, will keep the momentum generated by this incident going, as the impetus for change will not come from any where else.
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