The parents of the 13 children who died at the Karl Heusner Memorial Hospital (8 of them from the Enterobacter cloacae infection) will never know what exactly caused the tragedy.
An assessment carried out by a team of Pan American Health Organisation (PAHO) experts on the cases was inconclusive and unable to determine the source of the infection. Further testing by the PAHO team could not be done because the original samples taken from the babies were discarded as a result of “constrained space” at the Central Medical Laboratory.
“There is nothing sinister about it,” defended KHMH CEO, Dr. Francis Gary Longsworth, when asked why a critical aspect of the investigation was not secured. He further explained, during a KHMH conference held on Wednesday afternoon that the infections spread rapidly, and by the time it was detected the samples had already been destroyed.While the investigation has hit a wall, the PAHO report was damning of the medical standards of the KHMH. It cited a myriad of gaps, weaknesses and gross neglect in the areas of infection surveillance, prevention and control.
The report pointed out that while the responsibility falls on the Infection Prevention Control Unit, this body was not functioning. This is why when the KHMH ignored one of the critical recommendations made two years ago on infection prevention and control, which mandated the elimination of early syringe preparation in pediatric and neonatology, no flags were raised.
In 2011, KHMH was told the practice was “high risk” but KHMH continued the practice of piling up prepared syringes and using it for multi patients as long as it was within 48 hours of preparation.
While the PAHO report did not directly link the practice to the contamination of the babies, there is a strong likelihood that it could be the case.
In their conclusion, the report cited that the “most plausible explanation” for the infection was “contamination of any device for intravenous puncture or intravenous medication”. Since all the babies who died were premature newborns, they were all received care and treatment with the use of intravenous medication.
When asked whether anyone would be held accountable, the KHMH and Ministry of Health CEOs Dr. Longworth and Dr. Peter Allen said no one could be held responsible because no one knows the source of infection.
Minister of Health Pablo Marin who agreed to answer questions only after the media insisted, said he was not to blame, not even for deaths caused by the serious malpractices at the hospital over which he presides.
“I do believe that it’s a small amount of persons blaming the Minister. In reality every health system has their problems, in any part of the world. The only thing we have to do is try to do our best to try the remedy all those problems that we have,” said Marin.While the Minister tries to wash his hands from any responsibility, and the KHMH authorities are hiding behind a vague report, the families of the children have received little remorse.
Hospital officials have met with the families twice but not to claim responsibility and offer compensation. In the second meeting, held on Monday June 17th, at least two mothers say they were accused of causing the deaths. In this meeting, attended by the KHMH CEO and Minister, one of the mothers was offered a scholarship as a form of appeasement.
