Diary of a bereaved Mother: Chapter 5 part 3

25 September 1989,

I didn't sleep last night, I was coughing all night. I rang the Landscape Road Plunket. The Plunket nurse took me to Dr Lim's surgery. He was concerned about my weight loss. I had dropped in a week from 65 to 62 kg. I must have looked a mess.
He rang National Women’s to admit me. He said they may have to induce me.
There was protein in my urine. I had excessive amniotic fluid. The Plunket nurse sent me home to pack my bag and the girls stayed in the Landscape Road rooms.
There should have been alarm bells right from the first scan. When we read the scan reports after requesting them from the hospital after Andrew was born. I was very angry.
On 25th September 1989, Monday, I was admitted to Ward 5, referred to by my GP Dr A Lim at 38/40. I had been coughing for nine weeks, had a weight loss of 4.05 kg from 25 July and 2.2 kg on 7 July. I was vomiting and had insomnia and my overall weight gain was only 6 kg. I had ultrasounds done from 14 June 1989. There was a question of skeletal abnormality as the femurs were bent. I had four scans done in Greenlane Hospital, all with the same results.
There was protein in my urine, and I had a lot of water in my uterus. Subsequently I researched and found that excessive amniotic fluid (hydramnios or polyhydramnios) was a sign that babies are not normal, and certainly one of the warning signs of a Campomelic baby. Yet nobody picked up this. Andrew could not swallow, and this may have attributed to the excess fluid.
Dr Lim said they might have to induce me. I arrived at Ward 5 at about 10.30am and was met by the nurse manager who was having her morning tea. I explained that I had been losing weight and not sleeping and was vomiting. She said she would send a dietician to see me. I thought to myself, I needed medical help. I was a 35 year old woman with two children and was a sensible eater. Not an anorexic teenager. A nurse took me to a room where there were three other women.
At about 12 noon, a young doctor came and asked me a lot of information. I explained about my weight loss, my coughing, insomnia when there were days of little sleep, and over the past 10 days, I had not been able to keep food down. I felt anorexic and drank only water and weak tea. He felt my stomach, my chest and my back. The nurse came and got a urine specimen. I specifically told him about the four ultra sound scans I had had done at Greenlane Hospital and expressed my concern because of the bent femurs.
Then a team of doctors came under Dr Brown. He took a blood sample and asked a lot of questions. As I was a Chinese woman, they were discussed whether I had got tuberculosis and wanted to X-ray my lungs. I was concerned about getting an X-ray at this stage of my pregnancy. Dr. Brown ordered an urgent ultra sound scan. It was lunch time and the Nurse Manager wasn’t happy that I had to go to the Radiology Department without my lunch.
A student from Carrington Tech took me down to the Radiology Department where she waited with me until 2 pm. During the scanning, I told the technician about the four scans I had had done in Greenlane, which was just next to the National Women’s. It appears the technical staff were not told of these.
She said, “I am glad you told me, because I wouldn’t know what I was scanning for.”
During the scanning, I saw that the femurs were still bent. I was very upset because during the fourth scan at Greenlane, the doctor had told me that the femurs were straightening out and would be alright by the time the baby was born. Then a man came to scan me. After he finished, I asked if I was going to be induced.
He said, “It is not my position to say so.”
Then I was told I was to wait for X-rays to be done. I was very upset. Though I heard the doctors at Ward 5 talking about it, they had not told me. I kept asking the technician if it was safe and she assured that they do a lot of X-rays for women at this stage.
After the X-ray, I went up to Ward 5 by myself. It was 2.30pm. There was no lunch for me, but I didn’t ask as I didn’t feel like eating.
At about 5 pm, a Chinese doctor came and identified himself as a consultant. He was H Tan. He touched my abdomen, and asked three questions :
Why are you here?
Don’t you think your baby is alright?
Can’t you remember from your previous pregnancies?
I was taken aback by his abrupt manner. I explained again the same things I had explained three times already during the day and about the important four scans at Greenlane Hospital. He said he would have a 24-hour urine test and some blood tests.
The hospital report of the scan done had this discussion:
The differential diagnosis includes:
1: Osteogenesis imperfecta
2: Neurofibromatosis
3: Diastrophin dwarfism
4: Camptomelic/campomelic dwarfism
5: Congenital hypophosphatasia.
There were no definite antenatal features to enable a firm diagnosis of these. Post-natal evaluation is required.
Nobody told us of these, the delivery suite didn’t have my files when I came to the theatre, the paediatricians were not told. Andrew had Campomelic dwarfism. One look at him, and the paediatrician knew something was seriously wrong. They could have picked it up from the scans, BUT THEY DIDN’T. Somebody had failed me badly.
During tea, I forced myself to eat a little while listening to the other women complaining they didn’t have enough to eat. I offered them my food which they took and ate heartily. They then told me not to tell the nurses because they were diabetic and were on a strict diet. They joked that they get their whanau or family to smuggle food in for them. They teased me about where my puku or stomach was because I didn’t look pregnant.
I was coughing badly, and the patient next to my bed suggested I ask the nurse for some inhalation because it relieved her coughing. I asked the nurse and she brought it to me. I would not otherwise have been given anything for my cough if I had not asked. The other women laughed out loud and joked that the patient was a doctor. They were a jovial lot. They were Maori women and had a strong camaraderie because they were all in the same boat.
At 9 pm, the nurses pushed my bed to the Day Room. They explained that this was so the women didn’t disturb me, and also that I wouldn’t disturb them with my coughing. I am sure it was the latter. I was sad to leave these ladies whom I had grown very fond of. They were sad too, because it was like being sent to Coventry. Maybe I was sent there to be punished for having given them food. I didn’t sleep a wink because I was coughing the whole night. At 5 am, I asked the nurse about the urine collection, and was told to start at 6 am. In the morning, I was pushed back to my new friends. They joked that I was back from solitary confinement. These ladies were in the room for months, some of them confined to 24-hour bed rest. All they could do was to crack jokes. My baby wasn’t due for two to three weeks. I couldn’t foresee myself in the ward for such a long time.
In the morning, at 8.30 am, the doctors under Dr. Brown came. He asked if I had eaten and if I had vomited. I said I had eaten but I didn’t tell him how much I ate. They were discussing what to do about my cough. The Indian doctor suggested codeine. I was upset because I had read about codeine and its effect on blood clotting. Dr. Brown said I was ready to go home. I was shocked and I asked about the 24-hour urine collection, and he told me there was no need for it.
I felt very upset because I didn’t think the doctors had done anything for my coughing, insomnia and anorexia. The nurse came with a monitor for the baby. She asked me to press the bell every time the baby kicked. The baby didn’t kick. I was too tired and mixed up to tell anyone. In fact I did tell Dr Lim that baby wasn’t as active as the other two. I just dismissed it as being because I was busy running around for Gabrielle.
(Dr Lim should have picked this up and informed the National Women’s. Babies with CS do not move very much because they can’t move their legs. Last evening, I watched an American documentary on “The man with half a body” Kenny Easterday, the boy with no legs. I wasn’t surprised to hear his mother say that he didn’t move inside her. Doctors should not undermine mothers. Mothers know when things are not right; doctors should not whitewash the fact but carry out a thorough investigation.)
I told the nurse I was very very tired, I had had no sleep the previous night, and I had a four-year old and a 16-month-old baby. I asked if I could stay and rest. She said yes, I could stay until before lunch. Then I was told to come to the day clinic on 5th October.
When I read my discharge note, I was very distressed. It read, “Apparently private Radiologist suggested abnormality.” I had repeatedly told them that the scans were done at Greenlane. I had never been to any private radiologist. On the sentence ‘normal foetal skeletal anatomy,’ before the word ‘anatomy’, the word ‘abnormal’ was scribbled out.
The next day, on Wednesday, I consulted our friend, Dr. Bobby Tsang. I asked him to interpret the notes and advise me who to contact to express my concern about my short stay and apparently unsatisfactory care. Bobby advised it was the doctor who signed the form. Bobby rang Dr Brown and was told that it was a joint decision of Dr. H Tan and himself. When queried about the private radiologist, Dr Brown was adamant that Greenlane did not do ultra sound scans of that nature.
(Of course, Dr Brown was wrong. When I had Deborah, it was also Greenlane that I had gone to. I do not know what assumptions he had made or if he had not bothered to check with Green Lane despite me telling them three times. Despite having his colleague Bobby Tsang querying him, Dr. Brown had not investigated with Greenlane Hospital. Had he done that, he would probably have followed up my case with more care. )
At 5.30 am, 29 September 1989, I started contractions at 10-minutes interval. I had been up since 3 am. At 7 am, I rang the delivery suite and explained that my second daughter was born two weeks early. My labour was 35 minutes, and Gabrielle was a BBA or born before arrival baby. We arrived in an ambulance. They told me to come in view of this.
This time-line was sent to the hospital and Dr Tan. Dr James read it and said no wonder we were so angry. Dr James was very surprised it was so well written. He asked for permission to use it for student training and hospital policy.
We had scheduled a meeting.
17 October 1989, we met with Dr. Tan with Dr James and Wendy Green. Dr Brown was no show.
These were CO’s observations:
1: when asked about his writing, “Normal” in my notes.
Tan’s interpretation:
Whereas Brown took it as normal, he said it was solely Brown’s decision to discharge Ann.
2: Tan said he was not able to comment on Dr Brown’s action.
CO: Do you think that as Head of the team, you have the ultimate responsibility for your junior’s action?
3: Concerning Dr. Brown, we expressed our wish to meet with him, but such a meeting had not taken place.
4: The doctors had not taken the scan reports with differential diagnosis seriously, nor informed the delivery suite of the seriousness of the nature or prepared them when Ann came.
5: Did not appear to have investigated the case fully for themselves and told the patient everything was alright, even though the doctors knew something was wrong. Reassurance from the doctor(s) seemed without solid foundation.
This is unprofessional.
The report contained nothing new, it was a whitewash.
6: Did not bother to check with the patient how she was feeling, or whether baby was kicking during the period of observation. The observation period was next to nothing. It started at 6 am, and by 8 am, Dr Brown had discharged her.
Tan said, since the baby wasn’t due for two weeks they didn’t think it was urgent.
5: The Team did not take what patients tell them seriously. Ann had told them four times she had scans done in Greenlane. Yet no one had bothered to make a phone call to check.
6: Dr Brown did not follow-up our query through his colleague Dr. Bobby Tsang. This to us was very unprofessional.
Since Tan said he couldn’t comment on Dr Brown’s actions, we expressed through Dr James that we wanted to meet with Dr. Brown, We never did. Months later, when we demanded an apology from him, the hospital said he had gone overseas. He didn’t have the courtesy to inform us, or at least send a note.
We were not happy with Dr Tan, that he shifted responsibility to Dr Brown. We feel that as a team leader, he should be ultimately responsible for his subordinates. He disregarded the fact that it was him who wrote the words, “Treat baby as normal.” And for him to then blame it on Dr Brown was absolutely unprofessional.
CO felt that Dr Tan had been patronising. He treated us as though we were uneducated immigrants. What he didn’t know was that CO was a Dr Chin, PhD in engineering, and I had a couple of degrees up my sleeve from Canada and New Zealand.
The whole issue of my antenatal care left me with a very bitter pill. It would not have brought Andrew back, but at least I would have been better prepared psychologically and not have to hear these words.
“Your baby is dying tonight.”
I would like to have better investigations; perhaps I could have involved Dr. Rowley and my friend Dr Bobby Tsang.