VICTORIA – A third party, independent external review into a stillborn delivery at Victoria General Hospital (VGH) in August has found the care provided was within time guidelines, and that anaesthesia coverage was not a factor in the tragic outcome of this case.
At the same time, VIHA is committed to implementing all the recommendations from the system review of obstetric services at VGH.
“Our deepest condolences go out to the family of the baby,” said Dr. Richard Crow, Executive Vice President and Chief Medical Officer, VIHA. “As a family physician myself, I know that the unexpected death of an infant is an incredibly tragic event – one of the saddest situations we have to deal with in health care.”
VIHA commissioned the third party independent review on August 19th after concerns were raised publicly about the possible role of anaesthesia coverage in the stillborn case. The review had two components: The first part was a system level review of obstetric services. This review is being publicly released along with VIHA’s initial response to each recommendation. The second part is a detailed case analysis completed under Section 51 of the BC Evidence Act, which cannot be released publicly.
The review was headed by Dr. Ward Flemons, a respirologist, Professor of Medicine at the University of Calgary, a member of the board of the Canadian Patient Safety Institute and longtime patient safety specialist. Review team members included Dr. Jan Davies, Professor of Anaesthesia, University of Calgary; Dr. Ian Lange, Professor of Obstetrics and Gynecology, University of Calgary; and Mary John, Manager, Antepartum, Labour and Delivery and Postpartum, Foothills Medical Centre.
“After examining this case detail the review team was quite satisfied that there was no delay in the provision of anaesthesia care to the patient,” said Dr. Flemons. “Although for a short period of time the anesthesiologist was responsible for two patients, which although not an ideal situation, did not have any untoward impact on either patient.”
The review found that once the decision was made to proceed with a C-Section, ‘the patient was quickly transferred a short distance to the Main Operating Room,’ and ‘upon arrival in the Operating Room the patient was met by the onsite anesthesiologist and a fully prepared OR staff.’
The review further notes that while a second, back up anaesthesiologist and obstetrician were called in, ‘their presence was not required for the C-Section to start because the onsite anaesthesiologist could attend to the patient.’
The review goes on to state ‘the C-Section began approximately twenty minutes from the time that the obstetrician first called for it.’ This is within the current Society of Obstetrician and Gynaecologists of Canada guideline that states that ‘emergency Caesarian Sections should be performed within approximately 30 minutes.’
With respect to the 21 recommendations of the System Review of Tertiary Obstetric Services at the Victoria General Hospital, they cover a range of areas from how tertiary maternal and fetal care services should be designed to achieve optimal outcomes; changes that will support optimal care delivery; how VIHA should respond when outcomes, design and delivery of care are not optimal; improvements that could be made in leadership approach, teamwork, achieving respectful relationships and trust; and the engagement of patients in decisions about improvements to maternal-fetal care.
“We were impressed by the dedication of the people that we met from VGH - Obstetrics, Nursing, Family Practice, Anesthesia, Neonatology, Pediatrics, the Labour Delivery Room, the Main OR, and Administration all seemed committed to providing the best service possible; we had no concerns about the health professionals at VGH,” stated Dr. Flemons. “However, we do believe there are opportunities to take a very good service and turn it into an excellent service. VIHA needs to enhance the working relationships between its Departments and help develop more of a teambased approach. The investment required to enhance tertiary-level obstetrics at VGH will require the cooperation of the Ministry and a province-wide model for this service so VIHA will need to work closely with Perinatal Services BC and PHSA on this. The review team was encouraged and impressed by the potential for an exceptional maternal-fetal program in Victoria and we look forward to hearing about the progress that is being made on this over the coming year.”
“We are grateful for the time, effort and insights of the review team,” concluded Dr. Crow. “Even before this review started, work was underway to address improvement opportunities, many of which are raised in this report. VIHA is completely committed to working with our staff and physicians to implement each of these recommendations as quickly as possible.”
The System Review of Tertiary Obstetric Services at Victoria General Hospital and VIHA’s response to each of the recommendations are available on line.