I got a note through my Social Worker, Wendy Green. It was from Carole Fleming, the secretary to the Medical Superintendent. She told me to collect copies of Andrew’s hospital records which she had photostatted. It was almost the end of the day when I got the note and I went to collect them. I quickly turned to those entries done on the 25th September 1989. The Monday when I was admitted to the ante-natal ward.
I went back to Ward 11A and perused the entries made by Dr Tan, the consultant who examined me on Monday the 25th. I couldn’t believe my eyes.
Dr. Tan wrote: scan – no evidence IUGR (intrauterine growth retardation)
-- no firm evidence of any bone abnormality.
Plan - Treat baby as “normal”
I felt sick to my stomach. I didn’t know what he meant by IUGR, intrauterine growth retardation but I remember Dr. A Lim telling me that the scans showed the rest of the body was much smaller than the head. I knew what Treat Baby as “normal” was, -- he didn’t do anything. It was I who had to suffer from this negligence. I sat down to write down the time-line for Dr. James. He asked me to write about myself and my pregnancy so that he and the doctors would know me better, and to present my case to the hospital.
Deborah: Date of birth 8 December 1984. Gynaecologist Dr Bruce Conyngham. We chose a private specialist because Ann was twenty-nine, and this was her first pregnancy. Conception as planned. Pregnancy and labour uneventful. Deborah was thirty-nine weeks gestation.
Gabrielle: Date of birth 5 May 1988. Under GP Lim. Ann was under Dr Lim for more than ten years. Conception six months after planning. Pregnancy uneventful. Labour and delivery was very quick, only thirty-five minutes while she was still working at the Accounts payable Department at the Auckland Hospital. Thirty-eight weeks gestation.
Andrew: Date of birth 29 September 1989. Under Dr Lim. Conception not planned. Ann’s pregnancy with Andrew.
Last menstrual cycle: January 1989.
Bad nausea in February, but pregnancy was not suspected as menstrual cycle was irregular since weaning Gabrielle in August 1988.
28 February 1989, first appointment with Dr. Lim, pregnancy confirmed.
28 March 1989, second appointment. Dr Lim informs that he was going for a nine-week holiday. His locum will take care of Ann in his absence.
24 April 1989, third appointment. Dr Raymond Chen. He was a young man and was concerned about my bad nausea. I had no weight gain and he requested an ultra-sound scan. My weight measurement by the clerk was 55.6 kg. Dr Chen was concerned. There was no cause for concern.
8 May 1989: 1st scan at Greenlane Hospital, Epsom.
The young technician took an exceptionally long time. He didn’t discuss it with CO or me. Then Jessica, a more experienced technician took over. She came back with Dr/radiographer. Again they scanned a long time. It must have been more than an hour.
They told us, because of the way the baby was moving around, it was very difficult to scan, and made an appointment for another scan in four weeks.
Official report: A less likely possibility is that this is a real finding, perhaps due to some kind of dwarfism such as osteogenesis imperfecta. For this reason we have recommended that the patient return in two week’s time for a further examination but if there was a family history of dwarfism then more urgent action such as an ultrasound examination by an independent operator is recommended. E. Steele
22 May 1989, Saw Raymond Chen, still nausea. Dr. Chen made no mention about the scan, just said, awaiting repeat scan results.
14 June 1989, ultra-sound scan. I went alone. Scanned by Jessica . Saw the two bents of the femurs at different locations. Two doctors came and asked if I had fallen at any stage. It was a possible explanation that I had fallen and broke the baby’s bones and they reconnected. A follow-up appointment was made for four weeks.
Report: Osteogenesis imperfecta may have to be considered.
22 June 1989. Dr Lim came back, I was still nausea. I queried about the scan. He said, “Can’t tell if there is any problem, there is no prognosis at this time.”
3rd Scan. Went with CO. I told Jessica that baby doesn’t seem to be moving like my other babies. Jackie had a list of things to scan as instructed by Dr Alistair Roberts of National Women’s. We had a quick look. Other skeletal defects, in particular: spine, jaw, limbs, various length measurements, ossification which is the process of the synthesis of bone from cartilage.
The femurs were still very bent.
Jessica went to consult the doctors.
The doctors came and Jessica did more scanning. She said all the rest of the body was normal.
“I am sure the baby is perfectly normal, when baby is born, let me know and I will come and visit you.”
Another appointment, and then a follow-up appointment for every four weeks according to Alistair Roberts.
Official report: Pre-natal bowing due to foetal packing is a possibility, as is osteogenesis imperfecta. A repeat examination in four weeks’ time is suggested.
10 July, Saw Dr Lim, nothing eventful.
14 July 1989. Fourth scan. I went alone. It was a different technician and doctor. Saw the kink of the femur had actually straightened a little or was less bent. It was a quick scan by the doctor, presumably by Dr. N Black. He said there was no more scans unless A. Roberts or Dr. Lim requested it.
He said it would save my time, not having to go to Greenlane.
The scan which measured the baby’s head was 31 weeks, and the rest of the body was 28 weeks of development.
It seems likely this represents a variant of normal but significant pathology cannot be excluded on the basis of ultra scanning alone and follow-up of the baby after birth is required. I note that the patient is now under the care of specialist at National Women’s Hospital and further scans at Greenlane do not seem necessary.
(I was never under any specialist in National Women’s. I don’t know how Dr Black made this assumption. He could have been the first in the chain of my mismanagement. I had never met Dr Alistair Roberts. After I got the report, I asked to see Dr Black him for an explanation. He never showed up or even wrote an apology. After Andrew was born, we were told Dr Roberts was the doctor in National Women’s hospital that the Greenlane doctors had consulted. Unfortunately, he had gone to America and nobody followed up with him. It was incredible that I could have such a seriously problematic baby; yet we were kept in the dark, and right up to four days before my baby was born, I was assured that I was having a normal baby.)
July 1989, I saw Dr Simon Rowley for Gabrielle at the Landscape Plunket Road rooms. I told him about the scans and he said he would see the baby when he was born. I should just tell the delivery people.
10 August 1989, Dr. Lim. I had a cold from July, there was no medicine and he didn’t mention about further scans though I was worried and asked him about it.
18 August 1989, Dr Lim. I asked about the scans. He said maybe baby was bow-legged. It was strange that the femurs should be bowed/bent at different places. Or baby might just have short legs.
24 August 1989, Dr Lim. I asked him about the scan report. Baby has a big head and short legs, which conjured ideas of a midget.
I pressed on about his head measurements. He said, his head from ear to ear was still within normal range, just his legs were short.
There was no need to worry. Still there was no prognosis.
He would request a paediatrician after delivery.
I told him about CO’s nephew who was Down Syndrome and still couldn’t walk at three.
I was already having a cold, was not eating and the cough was preventing me from sleeping. He prescribed Amoxil and Gee’s linctus.
30 August 1989, 4 September, 13 September, 18 September,
I continued to be sick, my weight was dropping. I was seeing Dr. Lim on a weekly basis.
21 September, I was very sick and rang Pregnancy Help. They came and took me to Meadowbank’s Plunket because the Landscape Road Plunket couldn’t take me. I vomited in their car. The Plunket nurse saw that I was very unwell and suggested I see the doctor or at least to let the doctor know.
I rang the doctor’s nurse and told her my condition and explained that the Plunket nurse was very concerned.
The nurse at Dr. Lim merely said, “Wait till tomorrow; if the condition still persist, then come in to see the doctor.”
Oh, Ann, it seems like you were mis-treated all along!!! And you were just too sick to be able to speak up and demand some answers. How could so many doctors be so negligent?? And everyone passing the buck to someone else!! It seems like no one knew what was going on, yet they didn't care to refer you to anyone who could find out! And now even this nurse! They should all be ashamed of those notes, and I hope many people see this when it is published so they will know to speak up, ask for specialists and be demanding!! And to stay away from some of these doctors.ReplyDelete