The death of a 55-year old man, which State Coroner Kamala Ponnampalam had found to have been “precipitated” by a head injury due to a “medical misadventure”, has stirred up a conversation among the public on healthcare standards in Singapore.
Based on findings of the State Coroner, made available on Tuesday (13 Apr), Razib Bahrom died of a heart attack and bleeding to the brain after the stretcher he was strapped into during a transfer between hospitals collapsed, causing a traumatic head injury.
Ruling the death as an unfortunate misadventure, the State Coroner recommended that the hospital conduct a review of the event and come up with specific guidelines to address the transfer of patients in similar circumstances.
Mr Razib was being transferred from Khoo Teck Puat Hospital where he was diagnosed with a heart attack but did not show improvement in his condition.
On 17 June 2018, a medical team from the National Heart Centre Singapore (NHCS) arrived with extracorporeal membrane oxygenation (ECMO) to support the patient’s heart function. He was then transferred to the NHCS from the hospital.
Unfortunately, the ECMO machine was low on battery power en route to the hospital.
While the medical staff on board had tried to plug it into the socket in the ambulance, they found that there was no power supply and the machine couldn’t be charged.
The machine went flat as the ambulance arrived at Singapore General Hospital.
Another problem arose when the ambulance driver began to unload Mr Razib’s stretcher.
However, the collapsible wheels of the stretcher did not deploy, causing the top of the stretcher to fall to the ground.
An investigation into the stretcher incident specifically found that those involved had not used the proper procedure when pulling out the stretcher from the ambulance.
The patient was then transferred to critical care, unsupported by the ECMO for about five minutes as the machine was powered up again.
After several agonising days and a CT scan showing bleeding in the brain and significant swelling and damage, the ECMO support was terminated in consultation with Mr Razib’s family.
He died within the hour on 21 June 2018.
Though Mr Razib’s head did not directly strike the ground when the stretcher wheels failed to expand, the coroner found that an acute heart attack and acute bleeding in the brain were the cause of death.
Independent medical experts appointed to assist in the case, however, found that the failure of the ECMO machine did not contribute to or cause the patient’s death.
While Mr Razib’s daughter highlighted that she was not informed of the risks of patient transfer, that the ECMO machine ran out of battery power, that SGH did not immediately inform her of the fall and that the stretcher had malfunctioned, the State Coroner said that there was no basis to suspect foul play.
It is difficult to predict if he would have made a good recovery, the coroner added.
In response to this news, netizens on the CNA Facebook page are calling into question the quality of healthcare service in Singapore and wondering about the standards of equipment maintenance in a country that boasts of its world-class healthcare.
Many questioned why the ECMO was not charged or why there was no spare battery in the ambulance.
One netizen asked about who is responsible for the equipment failure, specifically the stretcher which did not function as it should have.
A few commenters said they would not classify the incident as a “misadventure”, as the State Coroner stated that it could have been prevented if not for the negligence of the hospital in terms of proper maintenance of such equipment.
Another netizen noted how the whole chain of events was listed out for the purpose of reviewing the protocols at hand, yet there was no acceptance of “negligence” or “compensation” offered to the family.
One person wondered how a maintenance report could assess that equipment is in good condition yet have the equipment fail when used.
They compared such a situation to instances when trees were inspected by the National Parks Board, yet they became uprooted just a week after, calling into question the quality of these maintenance checks.