Premeditated Medical Negligence  facebook.com/kamagong.org (join us)

She died of Secondary Postpartum Hemorrhage

Sequence Events/Deplorable standard of health care !

Legal ACTION and JUSTICE

9th July 1957 - 19th March 2002

Mazmur 91:1-2 Orang yang duduk dalam lindungan Yang Mahatinggi dan bermalam dalam naungan Yang Mahakuasa akan berkata kepada TUHAN: Tempat perlindunganku dan kubu pertahananku, Allahku, yang kupercayai. 

Psalms 91:1-2 Whoever goes to the LORD for safety, whoever remains under the protection of the Almighty, can say to him:  You are my defender and protector. You are my GOD, in you I trust.

Maternal death: This site is dedicated to all mothers in Sarawak who have lost their lives due to improper, substandard and deplorable standard of Health Care. This is a story about Kam Agong a mother of 8 children who died 30 days after Cesarean Section  performed by 2 Doctors who were mere General Practitioners. Cause of death due to Secondary Postpartum Hemorrhage (severe bleeding).

Kam Agong from Long Semadoh Naseb Lawas Sarawak. Died due to Secondary Postpartum Hemorrhage (severe bleeding  48 hours after cesarean section). Below are the events that lead to her death and all other events and the legal process before we obtained the so call Justice. 

They will victimize the poor, innocent and ignorant.

They failed to monitor her and neglected her. They performed Cesarean with complications but failed to consult a Gynecologist. They discharged her in a hurry. Her condition deteriorated and they blamed it on her age. They knew something was gravely wrong with her and urgently discharged her for the second time. They sent her back to Long Semadoh hoping that she will die without notice.

Immediately after her death, came the medical officers removed medical documents and medications from our home. They told our family members that it was not their doing and that it was fated.

They thought that this family incapable of bringing legal action or understand what went wrong. And if the family brings legal action they can prolong it, discourage the family or out of court settlement  would be an option. They knew predicament of the Lun Bawang community from Long Semadoh.

One must ask why the doctors refused to refer her condition to a Gynecologist. Is it to protect their livelihood? Could it be, if mistakes were identified it could be detrimental to their career advancement in the medical profession. Could these be the reason why they refused to safe her life?

She was basically killed to cover their dreadful mistakes. To all those who have contributed directly and indirectly to her death and suffering only GOD can forgive you.

 World War Medal 1939-45

The daughter of Agong Dawat a Second World War veteran. Agong Dawat was bestowed with medal of honor by UK and Commonwealth Type Campaign medal Eligibility British and Commonwealth forces. Awarded for Campaign service. Campaign Second World War 1939-45. Agong Dawat - died 1995.

	Damages up to RM136,888
	Still awaiting answers from gov't

Orang Ulu family seeks justice for mother's death    Tony Thien | Mar 13, 09 5:29pm

A 30-year-old Lun Bawang woman and her West Malaysian husband are appealing in the Miri High Court against the quantum of damages awarded to them arising from a medical negligence suit following the death of her mother after delivery by Caesarean section in the Lawas District Hospital seven years ago.

Lawas District Hospital must be upgraded                                      

Umno, Taib not bothered.  This is Ketuanan Melayu UMNO .

No reaction from the Federal Government, the State Government from Minister of Health and the MP of Lawas P222 Y.B. Tuan Henry Sum Agong. Nobody took any initiative to contact us. Three school going children and 1 infant. Their father goes to work leaving the underage children at home with no one to care. Who is going to cook and educate these children. Government careless if these children went to school. The government chose not offer help or assistance despite knowing that a family of 8 lost their mother in a such a terrible circumstances. Do we all need to be rich and famous or affiliated with some prominent politicians or political party before we get any attention?

DON'T trivialise our mother’s death and our suffering.

1. A punitive damages and justified compensation for the family members. Especially for the 3 underage traumatised children and for Jeremiah Jordan who was only 1 month old when his mother died.

2. We want a proper, good and effective health care system in Lawas District Hospital all the Klinik Desa.

3. We want a proper Lawas District Hospital to be constructed with all the necessary equipments.

4. We want the Lawas District Hospital to have specialists.

5. We want the Lawas District Hospital staff to be properly trained and qualified.

6. We want ambulance services by land and air to all the villages including Long Semadoh and Ba'kelalan

7. We want a mandatory rule in Lawas District Hospital the all cases which are beyond their ability to be referred to a specialist with great urgency. If a GP performing any kind of surgery the patient by default required to be checked by the specialist. Kam Agong's case is a perfect example where the GP did the C-Section and not referred to a Gynecologist despite complications and yet she was not referred to a specialist for 30 days before she lost her life. 

8. We want a complaints bureau to be set up at the hospital.

9. We want the hospital staff to be monitor and to be reprimanded if they have not preformed their duties.

10. We want a public transport system with insurance within from Lawas to Long Semadoh and all the surrounding villages.

11. We want roads to be built all the way to Long Semadoh and Ba'kelalan.

12. We want all schools in Lawas constituency including Long Semadoh and Ba'kelalan to have electricity 24 hours.

13. We want the schools to have a proper hostel for the students and proper monitoring system.

14. We want competent teachers in all these schools.

15. We want a Secondary school to be constructed in Long Semadoh.

16. We want the school to have all the facilities equipped and well trained teaching staff.

17. WE DON'T WANT DRUGS AND ILLEGAL ALCOHOLS IN OUR COMMUNITY and anyone who are caught selling drugs and alcoholic beverages to children must severely punished and enforcement must be carried out regularly and effectively.

18. We want the people of Long Semadoh and the Lawas constituency to get jobs with adequate salary.

Dear friends, just want to let you know that I have updated kamagong.org, help us to lobbing for a better healthcare and well equipped and professionally trained hospital staff, school and education system, for a public transport, for job opportunities with appropriate remuneration, for proper schools with effective teaching staff and for proper hostel.

Generations after generations the communities in Lawas predominantly the Lun Bawang people have been neglected and they have accepted everything as fated. I hear them praying for a better life for a better future. But it has been almost 10 years after Kam Agong's death , nothing has changed.

 The children I have met in Long Semadoh are children of GOD we say. But when they go for their Secondary Education in Lawas where they have to stay in the hostel, they are not monitored and no guidance from their parents. Most of them will probably meet their family members once a year. So they go through adolescent couple with culture shock and freedom. During this adolescent period they are tempted to try every thing from not going to school, drugs, alcohol, smoking, clubbing at night.

If one ought to ask from a villager how many children from their village have been accepted in to the University or regarded as professionals for the pass 15 years. They probably say no more than 2 or 3. But how many of our children had visited the police station and the prison they will smile and say “oh ramai”.

Children have been neglected, by parents who cannot effort to travel from Long Semadoh to Lawas and by a careless government where failed to provide affordable public transport system. Parents are trying hard; they work very hard in their farms and paddy fields and some construction work, hopping that their children will be better than them but the system and Government have failed them.

This would have happen to my sister in law.

Before her mother’s death she was in Lawas, SMK Trusan Secondary School. She was faced with similar problems, she hardly went to school. When her mother died she was merely 14 years old, left with 3 younger siblings, 11 year old, 8 year old and 30 days old infant. Their relatives and the villages expected her to stay in the village looking after her siblings.

My wife and I decided to bring the whole family to Kuala Lumpur and educate them. If we decided not to bring them, they would have wasted their lives, would have become liability to the country and wasted human resource.    

We send her for tuition so that she can at least marginally pass her PMR examination. We took her back to Lawas, she set for her PMR examination. We transferred her school to SMK Perimbun Cheras which was the closest Secondary school. She got the worst class in the whole school for form 4, continued to be in the same class for form 5. We pushed her to study and helped her which ever way we could, it was difficult. But she managed to get 6 credits for her SPM, subjects that she managed to score credits; English, Maths, Sains, Bahasa Melayu, Seni and Pendidikan Moral. Not bad for a girl who hadly went to school during form 2 and form 3.

She applied for a diploma in nursing and Colombia Asia sponsored her with RM50, 000. She completed her final semester, finishing her diploma at the Pantai Nursing College. She is a staff nurse at Colombia Asia Hospital. The other 3 siblings are following her footstep. Now for these children their cause of life has changed. They will no longer be a liability to the society but a useful human resource and good citizens.

There are many hopeful families and children from Long Semadoh and Lawas waiting for a miracle. We know they need help. We have to only help and educate one generation and we will be able to change fate of the whole community.

We want these sorts of positive changes for all the poor children of Lawas Long Semadoh and every child in this beloved Nation.

If we can built the Twin Tower we can built a brighter future for our children.

Words of Alexander Solzhenitsyn, the well-known Russian novelist and Nobel Prize laureate (1970)

: "Justice is conscience, not a personal conscience but the conscience of the whole of humanity. Those who clearly recognize the voice of their own conscience usually recognize also the voice of justice."

Umno will never understand this.

kamagong.org

What Happen to Kam Agong ?

 On 19th March 2002 Mr. Padan Labo and his eight children lost their mother (Kam Agong). She died of  severe bleeding a month after the doctors have performed Caesarean Section (C-Section). C-Section was done at the Lawas District hospital on 19th February 2002 at the age of 44. 

While politicians play money politics, here our mother was miss treated, miss managed, refused treatment and left to die.

Kam Agong died during our 4th Prime Minister and it passed through our 5th Prime Minister's tenure and now we have the 6th Prime Minister. Will Kam Agong and her family receive justice under the new leadership?

Note we are of the opinion that this is not not mere death due to medical negligence BUT death caused due to refusal to act or by omission. It is a Homicide.

We demand for an Independent Inquiry and investigate everyone who was involved. We want the findings to be published.

Kam Agong could have been alive today but not so due to negligence of the concerned parties. From the beginning since admission in labour, management and monitoring was inappropriate.

i.e.

- the indication of C-Section

- the type of C-Section which is questionable

- intra partum management – with Primary Post Partum Hemorrhage

- post partum management

- finally management of Secondary Post Partum Hemorrhage

Noted by a Gynecologist

Signature on the Consent for m for surgery - we found out during the trial the defense lawyer DPP ask the witness Mr. Padan Labo (the husband of the deceased) weather he signed the form for the operation. The document was shown to him (Case note 26). He answered I have not seen this document before.

DPP asked is that your signature? He replied that is not my signature.

DPP asked, is that the signature of your wife? He replied that is her name but not her signature.

At this time this line of questioning stopped and during the cross examination the form that Mr. Padan Labo signed was the tubal ligation form.

Few Unanswered Questions:

1. Who signed the operation form?

2. Why it was falsified?

3. What was the motive?

4. Why signature on the BTL form signed only by the husband and not both husband and wife? When did they obtain this permission before labour or during and not during the prenatal visits?

5.  Who did the artificial rupture of the membrane?

6. Why there was 2 incisions?

7. Why there was no monitoring of the fetal heart rate (FHR) between 10.30pm to 2am.

8. When the cervix has dilated to 9cm (as indicated) delivery could have been done  through vaginal? Why choose C-Section?

9.  Why delay Em LSCS for more than 3 hours?

10. Why caesarian was only done at 4.15am (no recordings of contraction and FHR since 12.30 on the PARTOGRAPH)?

11. Why there was no indication of what time oxytocin was administered on the (PARTOGRAPH)?

12. Intra operative notes on condition BP 90/50 case note 39. The excessive blood lost during the surgery up to 2 liter what were the remedial measures taken to control blood lost? 

13. Case note 37 only shows the plan post operatively and the earlier portion the page is blank on the operative notes. We want to know whether Dr. Hasimah and Dr. Fazilah were competent enough to perform the surgery. Is she credentialed to do so?

14. We want to know the type of caesarian section done?

15. Why PARTOGRAPH and the Labour Chart (case note 33 and 34) only indicate the first hour 10.30pm on the 18th February 2002. We want to know why these two important documents are incomplete?

16. What caused the fetal distress? Even during surgery there was no abnormalities written except for TMSL. But the deceased lost 2 liters of blood?

17. IS THIS NOT COMPLICATION? Why she was not referred to a Gynecologist?

18. The excessive blood lost during the surgery up to 2 liter what were the remedial measures taken to control blood lost? 

19. The excessive blood lost during the surgery up to 2 liter what were the remedial measures taken to control blood lost? 

20. We want to know since Dr. Hashima and Dr. Fazilah not a Gynecologists she had a duty to refer the deceased to a Gynecologists when she encounter problems.  Why this was not done? She had 30 days. 

21. The management was, administration of Syntometrine in the hope that the hemorrhage will subside without further investigation and consultation with a proper Gynecologist: failure to diagnose the cause of the SEC PPH. Why she was not referred to a Gynecologist?

22. Hysterectomy was an option and why it was not referred or considered, when there was a serious complication SEC PPH up to a month. Why this was not considered?

23. The Date 1st March 2002 at the Clinic Kesihatan Long Semadoh the deceased was attended by JM Lily and Tia Tindin. According to them her wound was dirty and there was infection on her wound. The wound was still open and requires dressing and her uterus was bulky. They did not refer her to Lawas Hospital. Refer to case note 13 on the Plaintiffs’ Bundle of Documents (PBD). Appointment set on 8th March 2002 according to the records. Why she was not referred to a Gynecologist?

24. The Date 8th March 2002 Dr. Hasimah has gone to Long Semadoh to give talk to ladies in the village. On this day the deceased when for her appointment at the Klinik Kesihatan Long Semadoh, where she was checked by the Dr. Hasimah and she was treated for infections on her wound and JM Lily was a witness to it and JM Lily said that “Fundal height was still high”. She also said that Dr. Hashimah told the deceased that her uterus was still bulky because of her age. On what basis and finding is this? JM Lily claims that Dr. Hashimah treated her with antibiotics. There no appointments given.

25. Why she was not referred to a gynecologist?

26. The Date 14th March 2002 - Kam Agong suffers SPPH at her home.  At Lawas Hospital she was received by Dr. Fazilah. The deceased was admitted and they placed a pad on her vaginal to see if she was still bleeding. According to the JM Lily there was very little bleeding but there are no records available to conform this. No records of her BP and HB after admission. The Discharge summary mentioned about ultrasound but no report in the case notes. According to witness there was no blood transfusion but given drips (IV) and blood request was send to the lab. There was no active management to monitor the deceased condition and the cause of her massive hemorrhage. She was merely kept under observation for less then 48 hours. No blood transfusion.

27. Why she was not referred to a gynecologist?

28. The Date 16th March 2002 What attempts made to consult a gynecologist? Who was the person made these attempts and which gynecologist did they consult at the material time? We have requested for her to be transferred to Miri Hospital but there was no reply on the part of the hospital staff.  It is assumption that the condition will resolve and no need for further consultation.

29. Records (on the day of discharge, evidence to show that she has stopped  bleeding, even her vitals was not given, was there any form of treatment administered on the wounds for infections).

30. What was the reason to discharge her in such a hurry without appropriate, adequate assessment and consultation with a gynecologist? She was admitted in the late afternoon on the 14th March 2002 and discharged in the early afternoon on the 16th March 2002. She was only observed less than for 48 hours.