Maternal deaths: Urgent call for better record-keeping
The former chairperson of the South African Medical Association, Dr Angelique Coetzee says medical practitioners should normalise taking notes and recording every history regarding a patient upon admission.
Staff at the Westbury Clinic was accused of medical negligence after 32-year-old pregnant woman died at the facility.
An internal probe by the Gauteng Health department cleared the clinic’s healthcare workers of negligence, further reporting that correct protocols were followed at the time of Mirriam Singh’s admission.
READ MORE: GP Health probe clears Westbury Clinic of mother’s death
The postmortem report has revealed that Singh had a serious underlying condition which contributed to the deterioration of her condition within an hour of arriving at the clinic.
Coetzee says most medical negligence cases often succeed because the healthcare worker at the time has no recording of what happened during the patient's time at the health facility.
Coetzee added nurses must follow a protocol which involves an initial triage, physical examination, the medical history of the patient and finally the documentation of the whole process with time records.
“If it is not documented and there are no proper notes, then it was never done and it becomes very difficult to defend that health care person who was looking after the patient because in this case, it would be the patient’s word against mine.” said Coetzee
“It doesn't matter how many times the doctor or the nurse says they did a heart monitor or any monitoring if it was not documented properly, then, unfortunately, there needs to be someone held accountable, this can be a case of medical negligence”
Coetzee added that more accountability, communication and transparency are needed from the Department of Health.
She says independent committees and health ombudsman need to be created to investigate under-served communities, where there is a lack of resources and medical assistance inequality
“If we look at steps that need to be taken for the department to rebuild the community’s trust, there must be transparency, inclusiveness and communication by providing clear health initiatives, they need to make sure that the messages get out to the public,” said Coetzee.
She further said: “All this must be in a format that the public can understand, and there need to be apps, hotline and forums for real-time updates on health-related emergencies”
Coetzee added that inclusive decision-making, accountability, and meetings with communities need to be done by the department, including the marginalised groups.
She says this will assist in bridging the gap in transparency, under-serviced health facilities and inequalities.
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