The deaths of two men have been attributed to major flaws, failures and shoddy record-keeping, the Health Ombud has found, revealing some of the glitches in the South African health system, reports TimesLIVE.
The widow of a specialist physician, Dr Edward Mabubula (64), who died four years ago, on 3 June 2021, is seeking millions in compensation after learning that there was no documented record of his baseline clinical assessment before the routine oncology procedure that preceded his sudden collapse and death.
This after Health Ombud Professor Taole Mokoena released findings last week into the deaths of Mabubula and Pitsi Eliphuz Ramphele, who died at a Polokwane hospital.
Irene Mabubula had lodged a complaint on 20 May 2021 against the Wits Donald Gordon Medical Centre, accusing the facility of causing the cerebral air embolism and subsequent stroke her husband suffered after a procedure performed at the Wits Donald Gordon Oncology ward on March that year.
She said the centre should be held accountable and has asked for R20m in compensation for medical expenses, arguing that the air embolism occurred on its premises and constituted a medico-legal hazard.
Mabubula, a specialist physician and nephrologist who practised at Lesedi and Tshepo Themba Private Hospitals, had being diagnosed with metastatic colon cancer in December 2018. He also had a history of pulmonary tuberculosis and had developed pulmonary metastases, leading to lung resection surgery in 2020.
His medical history further included hypertension.
On 25 March 2021, he was attended at the medical centre as an outpatient, and a doctor connected a chemotherapy pump to his implanted chemotherapy port to enable continuous chemotherapy infusion at home over 48 hours.
No clinical information
On 27 March, Mabubula drove himself to the Wits Donald Gordon Oncology ward for the removal of the ambulatory chemotherapy pump.
He underwent routine Covid-19 screening, which recorded a body temperature of 36.5°C.
“The chemotherapy port was flushed while he was seated. The investigation found that except for a recorded temperature that was measured earlier, there was no documented record of baseline examination findings or other essential clinical information prior to the procedure,” the Ombud said.
Once the flushing was completed, Mabubula stood up to put on his shirt, suddenly felt unwell and collapsed. He received emergency care and was admitted to the medical ICU, where he remained until his death.
An urgent CT brain scan showed a right frontal cerebral air embolism.
Independent experts commissioned by the Ombud confirmed that the chemo-port flushing procedure caused the embolism. The embolism was “most likely venous in origin” and resulted from port flushing performed while Mabubula was seated, a position that may have allowed retrograde venous air movement, which worsened when he stood up.
Though rare, air embolism is a well-documented complication of venous access procedures.
Mabubula developed epileptic seizures from the cerebral air embolism, which led to a cardiovascular and cerebrovascular incident. A respiratory infection also contributed to his respiratory failure.
“The certified cause of death was natural, with respiratory failure as the immediate cause,” Mokoena said.
The Ombud found that the lack of documentation breached the National Health Act, which requires proper health records for all patients.
Recommendations
Mokoena said the investigation uncovered a complex case of cerebral embolism that was aggravated by the medical centre’s undocumented practice of failing to open or retrieve patient files and failing to record critical baseline clinical assessments.
An independent radiation oncology expert concluded that Mabubula’s prior lung surgery and history of pulmonary TB altered his thoracic anatomy and pressure dynamics, further increasing the risk of air embolism.
The Ombud ordered the medical centre to:
- Develop and implement formal protocols for oncology outpatient port-needle removal;
- Create and maintain a dedicated medical file for each patient, with full documentation of clinical assessments and procedures;
- Provide psychological support to Mabubula’s widow and affected family within four months; and
- Participate in a mediation process to resolve outstanding disputes.
“We require proof of implementation submitted to the Health Ombud,” Mokoena said, noting that the centre had already begun acting on the recommendations.
The Ombud declared the matter closed, saying it had been “thoroughly investigated and finalised” and that no further action would be taken by his office.
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