KNH report: Doctors cleared, nurse termed ‘not very stable’

Doctors who performed an unintended surgery on a patient at the Kenyatta National Hospital (KNH) have been cleared.

Additionally, the nurse singled out for wrongly identifying the patient has been described by a colleague as ‘not very stable’ due to injuries suffered in an earlier accident.

Appearing before the Parliamentary Health National Assembly Committee yesterday, Miriam Bera, said long working hours had fatigued her colleague Mary Wahome, who was also sickly.

The nurse, Health National Assembly Committee was told, Ms Wahome was still recuperating from an accident she sustained five months ago on her way to work at night.

“Night shift is a lot of work, almost 16 hours. You can hand over at 7:30am but you will leave the hospital at 9am, get home at 11am and you are still expected to be at work by 5:30pm,” said Ms Bera.

PATIENT WAS CONFUSED

She is also diabetic. On the fateful day, as documented in a report submitted by the Health Cabinet Secretary Sicily Kariuki from Kenyatta National Hospital Board, Wahome arrived to work late, past 5:30pm that day of February 19.

In her statement in the report, Ms Wahome is said to have delayed getting to the hospital on time due to her injuries that have made her frail. According to the report by the regulatory bodies, the medical error occurred at the point of labeling the patient by the nurse, prior to being wheeled in for surgery. Dr Jackson Kioko, the Director of Medical Services, who chaired the joint inquiry, delivered the report.

The team comprised Kenya Medical Practitioners and Dentists’ Board, Nursing Council of Kenya and the Clinical Officers’ Council of Kenya.

“The said nurse also admitted being aware that the patient was confused, but on being requested to deliver one John Mbugua Nderitu, to the trauma theatre, she went to Room 2 with a porter and shouted his names and she then prepared and labeled the ‘responsive patient’,” the report read. He was then taken to theatre with all the documents of John Mbugua Nderitu.

“The Committee finds that the competency of Dr Hudson Ng’ang’a Kamau, who undertook the surgery of the patient, assisted by Dr Mose Moraa, could not be questioned as his team reviewed the documents presented to them in theatre appropriately and thereafter undertook the proper procedure that would have been expected in a proper scenario,” the report read.

The doctors welcomed the findings with relief, saying they were happy that they had upheld their professional integrity by having done their due diligence during the surgery and after the error was identified.

The Committee questioned Wahome’s capability to work in the hospital, as she even testified while seated because she could not stand for long hours. 

IS SHE FIT TO WORK?

The Committee recommended that her regulator, the Nursing Council of Kenya look into her fitness to practise under such conditions.

Further, the Committee found KNH to have systemic faults that affected the work of doctors, nurses and anaesthetists.

“In view of the above findings the Committee holds that a surgical procedure was done on a wrong patient as a result of systemic lapses at KNH thus affecting the functioning of the different professional cadres who were working at hospital at the material time,” the report concluded.

Prof Mwang’ombe said all through the surgery that started at 11pm and ended at 5:30am the doctors were so sure of the patient’s identity.

It is only at 6:30am that Ms Wahome came running to theatre frantically saying she had released the wrong patient.

The trouble of identifying the patient was also alluded to by Gideon Mwangi, a nurse who was on duty during the incident. On that day, while Simon Kimani Wachira was not labelled, John Nderitu was. As revealed in the submissions made, labeling is done only when a patient is scheduled for theatre. The confusion started when Ms Wahome got into the ward and realised one patient was missing, by the name Francis Mutua.