Public Report on the premature birth and death of newborn twins at Vila Central Hospital – May 28, 1997 - Emalus Campus
The inquiry leading to this report was initiated in response to the complaint of the parents of twins who were born at Vila Central Hospital and who died shortly after birth. The complaint was directed against the Director of Health, Mr. Niowenmal, the Acting Medical Superintendent, Mr. Tarivonda, Dr, Sala and three nurses.
The mother of the twins gave birth at 31 weeks of pregnancy. The Ombudsman’s investigation revealed that her prenatal care was deficient in a number of regards. The prenatal clinic was understaffed during weekly visits and no advice or education was provided in addition to examinations. She did not have an opportunity to see a gynaecologist/obstetrician (g/o) during her pregnancy. When she was admitted in labour, no doctor attended her. The hospital at the time was understaffed with only two nurses on duty in the ward. A drug was administered which both the doctor on call and the nurses knew would be ineffective in stopping labour. Despite these shortcomings in care and treatment, the report, with the benefit of independent expert advice, concludes that even if the mother’s condition had been suspected and labour had been diagnosed earlier, the outcome would probably have been the same.
The Ombudsman’s investigation extended beyond the case of the complainant and the death of the newborn twins. It was revealed that between March 1993 and March 1997, there was no g/o at Vila Central Hospital. This situation existed despite a repeated offer by the British Government to fund a position and provide a doctor. The offer was withdrawn after the Director of Health Mr. Niowenmal failed to follow up on it for over 15 months. There had also been applications for the position of g/o from other qualified candidates. However, these too were not followed up. (See Public Report dated December 9, 1999)
Statistics showed that during the period that the Vila General Hospital was without a g/o, and experiencing a shortage of nurses and midwives, the rate of deaths of infant mortality more than doubled to 4.4%. The fact that over 2 million vatu was spent on a new sign for the hospital and the fact that 25 million vatu was reserved for overseas medical care for Government Ministers and their families during this time highlighted the lack of services at Vila Central Hospital. (See Public Report dated October 1, 1997)
At the time of the birth of the twins, the Maternity Ward was being supervised by Dr. Sala, a recent graduate of medical school who was serving an internship. He should have been supervised by a specialized g/o in this position given his intern status and inexperience. Further, Dr. Sala was granted provisional registration as a physician without the approval of the Health Practitioners Board as required and later granted full registration by the Board meeting without a quorum.
The Ombudsman found that Mr. Niowenmal was incompetent to be the Director of Health. He was directly responsible for the increase in infant mortality by not pursuing the matter of a g/o position at Vila Central Hospital. The former Acting Medical Superintendent, Len Tarivonda was also found to be incompetent in relation to administration. Dr. Sala was found to have acted improperly in accepting responsibilities which he knew were beyond his competence. The Ombudsman also found that the nurses in the Maternity Ward were not properly supervised. Two members of the Health Practitioners Board, Dr. Tambarisi and Mr. Fanua, both public servants were found to have breached the Leadership Code by placing themselves in a “position in which fair exercise of their public or official duties has been compromised.”
· That gynecologists/obstetricians be urgently recruited for Vila Central Hospital.
· That the former Director of Health Mr. Niowenmal not be re-apppointed to the Director’s position.
· That the Former Minister of Health Dr. Tambisari and Former Secretary to the Minister of Health Mr. Tiro Fanua not hold positions of public responsibility again.
· That Dr. Sala receive further training.
· That the Health Practitioners Board Act be reviewed.
· That the decision of the Health Practitioner’s Board to register Dr. Sala be considered null and void.
· That nurses and midwives, formerly employed at Vila Central Hospital but dismissed as a result of a strike be rehired.
· That the 25 million Government budget for the overseas medical care of Ministers and their families be cancelled or reduced in order to invest in the improvement of health care within the country.
Written by Edward R. Hill
UNDP Governance and Accountability Project
© Ombudsman of Vanuatu
Published here by University of the South Pacific, School of Law Web Site - www.vanuatu.usp.ac.fj