Woman who lost baby: MOH says NUH probe found that 2-hour wait didn't contribute to miscarriage

Rosalind Ang
The Straits Times
Apr 27, 2022

The Ministry of Health (MOH) has completed its review of the National University Hospital's (NUH) investigation into the case involving a patient who had suffered a miscarriage.

On Wednesday (April 27), MOH said the processes and communications did not contribute to the miscarriage, but there were gaps that needed to be addressed.

MOH said NUH had conducted a thorough investigation into the incident, which included reviewing video footage and interviewing all staff involved.

The investigation was carried out by a team of NUH senior doctors and nurses from the emergency department (ED), obstetrics and gynaecology (O&G) department and the clinical governance-medical affairs team.

MOH said NUH had instituted a rapid access protocol for pregnant patients with signs of labour, after triage at the ED, to be transferred directly to the delivery suite to be assessed by the O&G doctor, rather than being seen by the ED doctor first before deciding on a transfer.

However, due to the unusually high numbers of patients at the ED that night, and with the delivery suite being full, the process of immediate transfer to the delivery suite had broken down.

It resulted in the patient not being seen in a timely manner, said MOH.

To prevent similar incidents from happening again, NUH implemented the following measures:

• Patients who are pending transfer to the delivery suite will be triaged by the ED nurse and reviewed by the ED doctor who will communicate with the O&G doctor

• Pregnant patients may be evaluated using ultrasound at the ED if necessary

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

• Following a review by the O&G doctor, foetal heart monitoring will be done at the ED while waiting for a bed in the delivery suite.

MOH added that NUH has met the patient and her husband several times to explain what had happened.

Said MOH: "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 has shared NUH's investigation findings with the senior management of all public hospitals.