SINGAPORE, April 28 — There were gaps in processes and communication that needed to be improved at the National University Hospital (NUH) to prevent a recurrence of an incident where a pregnant woman lost her unborn baby, the Ministry of Health (MOH) said. However, it said that the hospital’s “overall assessment” was that this "did not contribute to the miscarriage".

In a press statement on Wednesday (April 27) night, MOH said that it has completed its review of NUH’s investigation into the case where a pregnant woman was allegedly left unattended for two hours at the hospital’s emergency department.

“MOH is satisfied that NUH has identified the gaps in processes and communication that had contributed to the incident and implemented the recommended corrective actions. MOH has also shared the findings and lessons learnt with all public hospitals,” the ministry said.

Following the incident on March 15, the hospital conducted a “thorough investigation” of the incident, which included reviewing video footage and interviewing all of the staff members involved.

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The probe, MOH said, was conducted by a team of senior doctors and nurses from NUH's emergency department, obstetrics and gynaecology department, and the clinical governance-medical affairs team.

Commenting on the incident, MOH said that the hospital had instituted a “rapid access protocol” for pregnant patients with signs of labour at the emergency unit.

After a triage, where patients are examined in order to decide which ones are to be treated first, she was to be “transferred directly to the delivery suite to be assessed by the obstetrics and gynaecology doctor, rather than being seen by the emergency department doctor first before deciding for transfer”.

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“However, in this case, due to the unusually high numbers of patients at the emergency department that night, and the delivery suite being full, the process of immediate transfer to the delivery suite had broken down, resulting in the patient not being seen in a timely manner,” MOH added.

Following the incident, NUH has since put in place measures to strengthen the care of its patients and to prevent similar incidents from happening again. These include:

•           Patients who are awaiting transfer to the delivery suite will be triaged by the emergency nurse and reviewed by the emergency department doctor who will communicate with the obstetrics and gynaecology doctor as clinically indicated

•           Based on clinical assessment, if indicated, pregnant patients may be evaluated using ultrasound at the emergency department

•           A standardised obstetric assessment score will be used in the emergency department to triage pregnant patients

•           Following review by the obstetrics and gynaecology doctor, foetal heart monitoring will be done at the emergency department while waiting for a bed in the delivery suite

MOH also said that it has reviewed the investigation report submitted by NUH and is satisfied with the hospital’s findings.

“The corrective actions are also appropriate to address the gaps identified.” 

It added that NUH has held several meetings with the patient and her husband to provide clarifications on the facts of the incident.

“The couple has since accepted NUH’s clarifications and acknowledged that the miscarriage may not have occurred at the hospital.

"NUH has also assured them that the hospital is improving its processes to prevent future occurrence of similar incidents,” MOh said.

The ministry has since shared the hospital’s investigation findings with the senior management of all public hospitals.

‘In addition, MOH has also reinforced to the public hospitals the clinical standards for the management of obstetric emergencies.” 

Earlier this month, Dr Janil Puthucheary, Senior Minister of State for Health, told Parliament that NUH's investigation into the incident had found that although there were no lapses in clinical care processes, the hospital could have improved the way it communicates with its patients.

He added that the hospital has addressed this gap and instituted changes to its processes to ensure that relevant information is provided in a timely manner.

Health Minister Ong Ye Kung previously said that MOH would work with the hospital to investigate the incident.

He said last month that the authorities take a serious view of such incidents and that “any lapses or shortcomings” will be rectified. — TODAY