AIMS Ireland last week welcomed the verdict of medical misadventure in the Coroner's Court following the inquest into the death of Bimbo Onanuga in the Rotunda in March 2010.
Bimbo Onanuga died following a medical induction with Misoprostol/Cytotec 29+ weeks into her pregnancy due to the intrauterine death of her baby. Eyewitness accounts describe a catalogue of errors and failures to provide basic care to Bimbo that day.
AIMS Ireland are calling for a HIQA review into the death of Bimbo Onanuga
A Catalogue of Sytematic Failures in Basic Care
* Despite conflicting reports, Bimbo Onanuga disclosed her full medical history on booking at the Rotunda. Women are encouraged to disclose full histories in order for their care team to pre-empt any complications which may arise following some medical histories. Gynaecological procedures and investigations, abortion, surgery, injury, previous mode of birth, and more are all histories in which can affect the care paths of women.
* It is the responsibility of maternity providers to ensure individual assessment and appropriate care to women, regardless of her history. It is also the responsibility of maternity providers to inform themselves of women's previous history in order to develop the safest care plan for each woman taking into account her medical history, current pregnancy, her concerns, informed choice, and potential complications.
* It is the responsibility of care providers to listen to concerns raised by women and their families. AIMS Ireland encourage women and their birth partners to express concerns, unusual sensations or pain, if something doesn't 'feel right', and side affects to their care providers. It is the duty of care providers to listen.
* It is the responsibility of maternity providers to ensure that all staff are fully trained on how to provide basic clinical observations and record them in a timely fashion.
Bimbo's failure of basic care
* Bimbo Onanuga was nearly 30 weeks pregnant and was medically induced with Misoprostal on the Gynaecological ward rather than the labour ward.
* One of the principal carers for Bimbo Onanuga during the time of her induction on the gynaecological ward of the Rotunda Hospital was a nurse, not a midwife. The necessary clinical skills for diagnosis and treatment of labour, induction, complications, and basic issues such as experience in palpitation of the uterus are outside the scope of practice for a nurse and require the professional skills of a midwife.
* Bimbo was administered two doses of Misoprostol of 200mcg at three hour intervals - one vaginal and one oral. Recommendations from RCOG state that (I) induction of labour using Misoprostol is not recommended (II) Misoprostol should only be given orally, not internally (III) recommended dosage is 50-100mcg by four hours.
* Misoprostol is an off-label drug. This means that staff are not required to record adverse outcomes relating to this drug. Misoprostol has been linked to uterine hyperstimulation and uterine rupture in women with scarred and unscarred uteri. There have been recorded instances of rupture in first time mothers whom were given Misoprostol for induction of labour.
* Bimbo reported to be in 'constant' pain. It is reported that Bimbo was told as the pain was constant, rather than waves of contractions, she was not in labour. Concerns raised by Abiola that Bimbo was experiencing constant and severe pain were reportedly ignored and midwife Shiela Lynch is reported to have said she was exaggerating. Constant and severe pain is unusual and suggests something is out of the normal progression of induction. This was not recognized as 'abnormal'.
* Bimbo's partner Abiola reported that Bimbo could not breath or talk. His attempts to raise the alarm were not followed through.
* On Bimbo's collapse, it was Abiola who first initiated CPR
* It is reported that on Bimbo's collapse the available machine for measuring blood pressure appeared not to be working. Rather than taking the blood pressure manually, staff spent time attempting to get the machine working again.
* On Bimbo's collapse the medical team prepared for an emergency Caesarean Section. However the bed was too large to fit through the door of the Gynaecological ward and subsequently, an immediate Caesarean Section was instead performed on her bed on the Gynaecological ward.
* There are concerns relating to the medical notes the day Bimbo died. Notes were retrospective, out of sequence, were incomplete, and clinical observations were not recorded.
* Following Bimbo's death investigations were undertaken very quietly through the HSE. At no point was any information made public. Bimbo's death did not receive a full HSE inquiry. Bimbo's death did not receive a public apology. Following 3 PQs, recommendations into HSE investigations into Bimbo's death were released.
* Following the PQs, the HSE released a statement expressing its sincere sympathies to the family involved. However, the family were not contacted directly and are unaware of the statement
* The initial request for an inquest into the death of Bimbo Onanuga was denied by the Coroner ruling she died of natural causes. This was later reviewed and an inquest was granted.
These are the recommendations from the HSE following investigations into Bimbo Onanuga's death:
1. The need to identify clinical pathways relating to management of women with an intrauterine death in third trimester to complement existing medical management policy.
2. The Guidelines for Medical Management of Intrauterine Death should be revised in line with a review of the medical literature.
3. Details of all patients for Induction of Labour, regardless of place of induction should be centrally documented.
4. This recommendation cannot be disclosed as it contains personal, private, sensitive and confidential information relating to the individual patient.
5. Develop a brief operational outline of the Gynaecology Department to assist staff who are sent there on an occasional/intermittent basis.
6. Due to the complexity of work, there is a need for an updated training needs analysis of all midwifery and nursing staff on the gynaecology ward.
7. There should be a designated individual with responsibility for coordinating, monitoring and auditing the Basic Life Support attendance and Advanced Life Support Skills attendance, ideally a designated Resuscitation Training Officer.
8. An Obstetric Early Warning System should be introduced and evaluated.
9. Install additional phone lines in the ward.
10. A review of the possibility of emergency call bells or designated phones for emergencies in each room should be carried out and measures taken to address this.
11. Hospital wide analysis of all doorways in clinical areas to establish the feasibility of moving a bed in a critical event.
The Rotunda is reported as having changed their guidelines for the management of intrauterine death and fully implementing the 11 HSE guidelines.
However, it is important to note that guidelines on the HSE/RCPI/IOG websites (revised October 2013) are unchanged and recommend the same management guidelines which were in place the day Bimbo died; Misoprostol dosage and scheduling 200mcg by 3 hours.
AIMS Ireland call for a full HIQA review into the death of Bimbo Onanuga and review of guidelines for Management of Intrauterine Death to come in line with those of the UK and RCOG