The Coroner inquiring into the cause of death of Lagos-based pastry chef, Peju Ugboma, has indicted the doctors at a private hospital, Premier Specialist Medical Centre, for negligence.
The coroner, Magistrate Mukaila Fadeyi, said that the “only logical conclusion that one can reach is that the deceased died as a result of a combination of lack of due diligence and adequate investigations of her health status before embarking on the surgery, substandard care, inadequate monitoring and the failure of appropriate response to abnormal patient’s vital signs”.
His verdict is coming almost two years after the mother of two died after suffering internal bleeding following an elective hysterectomy operation for a fibroid condition at the Victoria Island based hospital in April 2021.
Until her death on 25 April, the 41-year-old Peju was the founder of a pastry company, I Luv Desserts.
After the surgery in April, she complained of severe abdominal pain and discomfort. Her blood pressure dropped to as low as 50/30.
She died after she was referred from Premier hospital to EverCare Specialist Hospital.
At Evercare, it was discovered that she had no pulse, and a subsequent CPR to revive her, failed.
The deceased husband, Ijoma Ugboma had accused Premier hospital of negligence resulting in her premature death.
In May 2021, the coroner’s inquest commenced to unravel the cause of death.
In June, the Lagos State Government through the Health Facility Monitoring and Accreditation Agency (HEFAMAA), shut down the intensive care unit of the hospital, pending the outcome of its investigation.
In the same June, the Federal Competition & Consumer Protection Commission (FCCPC) also commenced its public hearing to determine whether there was any violations of applicable consumer/patient protection standard in the death of late Peju Ugboma.
Doctors from the hospital failed to testify at the public hearing. They claimed that the Medical and Dental Council of Nigeria, MDCN had ordered them not to because the Council was also looking into the issue.
A total of 16 witnesses, however, testified before the coroner including the widower, doctors, pathologist and others.
In his verdict which lasted about 5 hours today, the coroner also said that careless entries in the early observation charts, as well as poorly documented case notes on the monitoring of the deceased and failure of the immediate involvement of the operating surgeons in her case of post-op complication as well as the absence of vital medical devices like the CT scan to detect Intra-abdominal bleeding also contributed to how the deceased died.
“There was an unwillingness of the doctors and consultants to return the deceased to the theatre to arrest haemoperitoneum haemorrhage and the lack of urgency to transfer her to another facility until it was too late”
The coroner who held that Premier Specialist Medical Centre owed the late Peju a better duty of care than she got also frowned at the use of part time doctors especially when he noted that the hospital’s doctors who were indicted by the medical panel of inquiry were part time doctors.
He said, “I am of the mind that a doctor who has two places where he works, locum and permanent will be more committed and dedicated at the permanent job more than the part time job.
In the end, Magistrate Fadeyi concluded that “the late Peju Ugboma was a victim of serious avoidable medical negligence occasioned by the actions and inactions of the hospital” .
The coroner commended two doctors, Dr. Ekido Okpiabele and Dr. Victor Raji who testified according to their good conscience and didn’t attempt to cover up their medical colleagues, the effect of which helped the inquest to arrive at a just conclusion.
Recommendations
After his verdict, the coroner made some recommendations to forestall a possible recurrence of such an incident.
Magistrate Fadeyi recommended that the code of conduct and ethics of medical practitioners should be tightly reviewed to severely punish negligence in cases of breach of duty of care to their patients.
He also recommended that the state government should not limit funding to only government hospitals but should render funds to private facilities to buy equipment.
He also took the view that government and regulatory agencies should ensure that the standard PCV of the World Health Organisation (WHO) be strictly followed for both sexes before a surgery is carried out.
The coroner further said that government and regulatory agencies should do more sensitization on the rights of patients especially in cases bordering on medical negligence
After the coroners verdict, the widower, Mr Ugboma, while speaking with journalists expressed satisfaction with the verdict.
“I’m very happy with the outcome of the inquest, it’s been a very long one. The circumstances of my wife’s death were not satisfactory,” he said.
“I know that tonight, my children will also be happy because they actually told me to send them a message to their teacher in school as soon as the ruling is out.
On his next steps, he said that his lawyers will advise him.
“I’ll be talking to the lawyers, we have a list of options. This is the end of a chapter but we are still not done with the process. This is fact finding and after this, I think the doctors need to be held accountable,” he said.
