A Death Must Never be Wasted

In 2012, Savita, a young pregnant Indian lady attended a hospital in the west of Ireland. She’d presented with back pain and was subsequently found to be miscarrying. After some time in hospital, she began to shiver, shake and vomit. She subsequently collapsed and was found to have an infection. She was started on antibiotics and taken to the operating theater to have the contents of her womb removed. On return from the theater, she was found to have low blood pressure and heart rate. She was eventually moved to the intensive care unit where she experienced multi-organ failure and ended up dying. An autopsy carried out after her death showed that she died from a really bad infection in her blood called sepsis.

Savita

The death of Savita went on to become a sentinel event. Multiple reviews were carried out and many lessons learned. One particular review done by the Irish agency responsible for health quality indicated that:

‘The clinical governance arrangements were not robust enough to ensure adherence to guidelines on sepsis’.

This and other reviews into the case initiated several cascades of programs, procedures and roles to forestall future occurrence of a similar event and improve general care for the population.

The Irish health service now produces annual reports on sepsis and carries out ongoing audits and training to improve the recognition and care for sepsis, a life-threatening condition. All doctors are now tasked with asking themselves whenever they encounter a patient; ‘could this be sepsis’. Once there is any suspicion, a form is to be filled and quality care properly given and documented.

Irish health service sepsis screening form

Savita died from sepsis rather tragically, however, her story was what the Irish health service needed to galvanize it to provide better care for its people. Irish nurses and doctors in undergraduate and post-graduate training now learn about her case and the appropriate way to manage similar conditions in a memorable manner. Programs instituted directly from her death have saved thousands of lives. The health system learnt valuable lessons and her tragic story has resulted in the saving of thousands of lives

The Nigerian Contrast

In November of 2016, Ifedolapo Oladepo, a member of the Nigerian youth service corps fell sick at a camp in Kano. She went to the camp clinic where she was alleged to have been treated for a ‘kidney infection’. Despite initial treatment, she deteriorated and became more unwell. She had to be transferred to a nearby general hospital where it’s reported that she didn’t respond to treatment and ended up dying. A panel was set up to investigate her death but are yet to publish a report. A young person dying with the alleged involvement of infection raises suspicion for sepsis. It’s now years later, where are the reviews? Where are the reports? Where are the quality improvements?

Ifedolapo

In April 2015, 36-year-old Mrs Dolapo Adesanya was pregnant with her 3rd child. She was in the 8th month of her pregnancy when she presented to the hospital with complaints of pain in her legs. She was reportedly given some pain killers and sent home. After a few days, she felt worse and returned to the hospital. She continued to complain of severe pains and went on to deliver her baby. Days after delivery, her condition deteriorated and she passed away in hospital. She was thought to have died from a clot in her lung. We, however, can’t tell for sure as she was buried soon after her death without the benefit of an autopsy. After many versions of what happened made the rounds on social media and blogs, the hospital came out with a statement of their version of events. No independent inquiry was ever set up and no reports issued as to the cause of death. Where are the reviews? Where are the reports? Where are the quality improvements?

Dolapo Adesanya

It’s well documented that conditions like sepsis carry a higher than usual mortality rate in Nigeria. One study from 2 tertiary hospitals in Southeast Nigeria showed that 7% of all medical admissions will have sepsis and 30% of them will die. Another study from Jos revealed that over 1 in 2 patients with sepsis ended up dying. Yet we do nothing about it. We continue our lackadaisical approach to the care of sick people in our hospitals. Dolapo the Youth copper died 18 months after her namesake endured a similar fate following childbirth. Had we taken advantage of the single-story like the Irish did in Savita’s case and instituted some systematic changes, our doctors and nurses would have been better prepared to avert an untimely death.

It’s a tragedy that 2 young Dolapos died in Nigerian hospitals and we are none the wiser today. As you read this, many more Dolapos are dying and will continue to die. We need to galvanize ourselves around single stories to take systematic action as opposed to defensive, one-dimensional behaviour typical of our health institutions. We must learn from poor outcomes and use them as opportunities to institute the programs, procedures and roles to bring quality improvement to healthcare. Our work as concerned individuals and society is to find those single stories that help us say unequivocally that enough is enough. We should never again let a hospital death go to waste!

Notes

Studies on sepsis mortality referenced above:

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