Kam Agong – death due to medical negligence This site was create with intention to highlight all the events that took place which lead to the death of our mother KAM AGONG. Cause of death: Secondary Postpartum Hemorrhage (SPPH) (Defination: Secondary PPH is defined as excessive blood loss from the genital tract after 24 hours following delivery, until six weeks post delivery. ) 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) at the Lawas District hospital on the 19th March 2002 at the age of 44. The plaintiffs are the eldest daughter Ms. Agnes Padan and her husband

The defendants are  Dr. Hasimah Bt Basri, Dr. Fazilah Bt Azali, Dr. Jaya Purany,  Dr. Lalitha, Jururawat Masyarakat Klinik Kesihatan Ibu dan Kanak-Kanak Long Semadoh Lawas, Pengarah Hospital Daerah Lawas Sarawak and the Government of Malaysia. Our mother Kam Agong and her family are from Long Semadoh Lawas Sarawak. They belong to an ethnic group call Lun Bawang.

According to Tom Harrisson (1959) and S. Runciman (1960), the Lun Bawang tribes are the once who started settlements in the highlands in the center of the Borneo Island. They are predominantly farmers and majority of them are of Christian faith belonging to the Borneo Angelical Church or (SIB). Kam Agong – she is a God fearing person and loving mother of 8. She was the cornerstone of our family. She took care of her children and helped them with their studies. She worked with the husband in the paddy field and assisted her husband with some construction work in her village. She taught her children to sing and to play music. She participated in the Church activities in the village. In the early years when there were no flights from Long Semadoh and no land transport from her village to the nearest town called Lawas.

Kam Agong able to walk for two to three weeks to Lawas from Long Semadoh carrying goods to sell in Lawas and with that money they will purchase some groceries and walk back all the way back to Long Semadoh. She was a strong lady and according to some villagers they have never seen her falling ill even after her normal delivery she recuperates very quickly. All her previous deliveries were normal. Some of us were delivered at home and in the and clinic.All seven previous deliveries very handled by mid wife and nurses except for the eighth child by doctors.

At the time of Kam Agong’s death the children were: Jonny Agong 1975 age 27 (delivered at Home mid wife) Andy Padan 1977 age 25 (delivered at Clinic by mid wife) Agnes Padan 1979 age 23 (delivered at Home by JD ) Danny Padan 1981 age 20 (delivered at Clinic by JD) Kathy Busak Padan 1987 age 14 (delivered at Clinic byJD ) Alister Samuel Padan 1990 age 11 (delivered at Hospital Lawas mid wife) Xtus Baru Padan 1992 age 9 (delivered at Home by Taya) Jeremiah Jordan Padan 2002 30 days old infant (at Hospital Lawas with caesarian section by Doctors)

Sequence Events 18th February 2002, approximately seven to eight in the evening Kam Agong had her contraction and her husband took her to the Lawas District Hospital for delivery. She was admitted at 9.45 pm. At about 10.30 Dr Fazilah the fourth defendant produced a form for Mr. Padan Labo to sign. It was consent form for tubal ligation. However around two in the morning the forth defendant have decided that she (Kam Agong) requires emergency C– Section and waited for the third defendant Dr. Hasimah until 4.30 in the morning. These are our findings after going trough the case notes (hospital documents) obtained from the Federal Council.

18th February 2002 – The deceased had labor pain and she was taken to the Lawas District Hospital at 9.45pm. According to case note 7 at 12 midnight her OS has opened up 7 to 8 cm and the head in at station +1. However the PARTOGRAPH indicates station +2. After that they monitored the condition of her cervix dilation and it progressed according to the normal PARTOGRAPH. At this time after she was monitored they said that she has gone into obstructed labour.

1. There was no evidence of obstructed labour which has been recorded or indication of obstructed labour. At about at 10.30pm to 11pm they did artificial rupture of the membrane. They found that light meconium staining.

2. After the 10.30pm they suppose to monitor the fetal heart rate (FHR) between 10.30pm to 2am but there was no record, despite the fact that there was evidence that there was meconium staining at 10.30pm. But they have recorded the there was no fetal distress at 10.30pm because they have recorded FHR at 140.

3. After 2pm only then the realized that there was fetal distress and the FHR 80-90bpm but by this time the cervix has dilated to 9cm (as indicated), no CTG recording at all. Hence if the fetal distress was not there, labour would have continued until delivery could have been done through vaginal.

4. Even after 2.30am until the point when they went for the Em LSCS there was a delay of 3 hours. No monitoring done in between to see if the baby has gone down to station and could have been delivered earlier time then caesarian section . Caesarian was only done at 4.15am (no recordings of contraction and FHR since 12.30 on the PARTOGRAPH).

5. No indications of what time oxytocin was administed on the (PARTOGRAPH). – to be commented only if the defendant oxytocin given. The recording time of oxytocin drip is vital in the labour record and partograph (oxytocin will enhance the delivery process and should be monitored). And injudicial use of oxytocin when prolonged in labour is one of the causes of fetal distress (because of cord compression).

6. Before c-section that PH reading of the fetal blood from the scalp to determine if it is less then 7.25. This is the true indicator of less oxygen, was this done?

7. Question of c-section arised only after the normal labour had progressed, why there was fetal distress when there was no indication. The labour was considered normal because she had seven normal deliveries and PARTOGRAPH supports the progress of the cervical dilation. It is only recorded until 2am 19 February 2002.

8. Discharge summary and the post operative notes have noted obstructed labour when there are no specific reasons mentioned. Inaccurate diagnosis recorded. Diagnosis of obstructed labour was not mentioned in the case notes before post operative report.

9. Only one reading of fetal heart rate (FHR) was indicated when it was low. But there is no evidence and the Labour Chart is incomplete after 10.30pm.

10. Case note 34 indicates that the FHR was normal at 10.30pm on the 18th February 2002 but they also indicated the there was SMSL (slight meconium stain). This Labour Chart is not the original copy and it has been conveniently fabricated (case note 33).

11. The deceased husband stated when he was questioned by the defense lawyer, is that your signature on the consent form for the operation, he replied no, and if it was the deceased signature he replied no. But the Dr. Fazilah had asked the deceased husband to sign another document which was the consent form to perform tubal ligations (BTL) which should have been signed by both the deceased and her husband however it was only his signature that was required. Who signed on the consent for the operation form?

12. From 10.30pm to 2am there was no FHR recorded as it should have been.

13. Monitoring was neglected after 10.30pm and 2am on the condition of the fetus and the maternal vital signs. The only thing was recorded was the dilation.

14. The dilatation of cervix was normal.

15. Three hours later, the FHR was documented indicates 80bpm to 90bpm and they have decided to perform C-section. Is there a possibility that the heart rate obtained was maternal in origin? In this case the diagnosis of fetal distress and C-Section performed justified (no CTG recorded).

16. If the change in the FHR was detected earlier then the fetal distress would have been predicted earlier. But they did not monitor and did not do it. Should they have done this recording they could have done Em LSCS earlier.

17. Decision for C-Section was 2.30am and C-Section performed at 4.30am. Why was the delay? Em LSCS for fetal as per NIA (National Indicator Approach) should be performed within 30 minutes. Why were the fetus and the mother not monitored during this period?

18. The fetus may have been in distress for more then 3 hours. Within such time the baby could have been delivered or C-section could have been completed.

19. There was no monitoring after 2am and no record.

20. Case note 34 incomplete and not the general practice and it could have been written after delivery.

21. Two PATOGRAPH one was canceled. Indicates that they should go for C-section earlier. Case note 42. If this is the true PATOGRAPH then the labour was not proceeding.

22. We want to know why the there was a prolonged labour? Deceased admission date was 18 February 2002 at 9.45pm. There was contraction started at 7pm at home. We want to know if the hospital did an ultra sound to measure the head of the fetus for any possible obstructed labour. The child was only delivered at 4.38am.

23. We want to know what happen between 9.45pm 18 February 2002 till 4.38am February 2002.

24. We want to know the reason for caesarian either obstructed labour or fetal distress. The admission was 9.45pm but she has been having contraction since 7.00pm. The fetus head was engaged in position and the heart rate was 140 as indicated in the case note 1. Time not indicated on the case note 1 but on the PARTOGRAPH time indicated 10.30pm, 11.30pm and 12.30am but what was the following reading after 1.30am?

25. There was a trial of labour from 9.45pm until 2.00am when the FHR dropped to 80-90bpm. Only then the MO was called i.e. Dr Fazilah. What was the FHR reading before 2pm? Why it was not recorded in case note 34. Why did they wait till the FHR to drop before they could call Dr. Fazilah?

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

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

28. 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?

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

30. With regards to the doctor’s decision to perform caesarian section. We want to know the type of caesarian section done. It is indicated that the doctors had performed a Lower caesarian section but one document indicated that it was a classical caesarian section this could have contributed to her blood lost. The indication c-section of the deceased does not justify a classical section (this is only performed on a very special circumstances). And why the doctors could not decide whether it was obstructed labour or fetal distress? If they were not competent why the doctors did not seek help from a gynecologist post surgery when complication arised?

31. We want to know since Dr. Hashima is not a Gynecologists she had a duty to refer the deceased to a Gynecologists when she encounter problems. Why this was not done? They had 30 days. After the caesarian

32. What caused SEC PPH?

33. Syntometrine was ordered by Dr. Hasimah to be administrated at home on the 18th March 2002. So it is apparently evident that Dr. Hashimah noted that there was still bleeding. Is it a practice to give such medication without further investigation and assessment?

34. 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 and no mention in the hospital notes.

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

36. On follow up the baby Jeremiah Jordan Padan was treated repeatedly for excessive mucosa retention in the lungs. The doctor treated him with high dosages nebulizer and pediatric solution to remove the excessive secretions. Had commented that his condition is continuing because of delayed delivery.

37. On the 14th march 2002 500ml of fresh blood – HB recorded 90/50, pale anemic indicated but HB recorded 10.2 does not make sense. Request for PER-OBST- 306 NOT AVAILABLE

38. Blood lost at PER-OBST-305 was 1.7liters but in the PER-OBST-304 indicated 200ml. and there are lots of discrepancies.

39. 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?

40. 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. Why she was not referred to a gynecologist?

41. Second Admission 14th March 2002 On the 14th March 2002 in the morning she started bleeding. In was indicated fresh blood in the case note 13. There was a drip set and she was administered syncometrin an agent to contract the uterus hence it stops bleeding. Her vitals were bp 90/50, HB 10.2 (recorded at 12.25pm) according to record with pallor and pulse 78. On the way to the Lawas Hospital, JM Lily (nurse) stopped call to the Lawas Hospital to inform them that the deceased was in a state of shock and she has lost approximately 500ml of blood. 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. Why she was not referred to a gynecologist?

42. 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.

43. 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). 

44. They took blood for test, she appeared very weak, the hospital staff said that she was completely alright and no more bleeding and she can return home. The deceased continued to stay in Lawas at Minah Tagal’s home. She was even weaker and not well than the time of delivery. Appointment was given 1 month later on the 16 April 2002 Klinink Kesihatan. The HB has been altered from 8.0 to 9.4 on the discharge summary, what was the reason to do so and no official report on this HB. It is not normal for a person who had delivered one month ago to persistently bleed and have such low HB.

45. 18th March 2002 The deceased went up to Long Semadoh. Her daughter Ms Kathy Busak Padan has noted that her uterus was bulky, infections on her wound, there was pus and her pads were soaked with blood. This was noted in the evening. But in the discharge summary there was discrepancy about the infected wound. Which probably written routinely? And only observation stressed in the discharge summary dated 16th March was minimum lochia (with in 3 weeks discharge of lochia should have resolved). 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.

46. 19th March 2002 Our mother died of massive bleeding (Secondary Post partum Hemorrhage), on the way to Lawas District Hospital. No postmortem was done. Probable causes of blood lost:

1. PPH primary and secondary

2. Retain products of conception

3. Uterine atony (not contracted well).

4. Uterine extended tear.

5. Lost coagulating factor with excessive blood lost during surgery? DIVC.

6. 11 pads fully soaked in 2 days not normal.

7. Egomatrin was given but not monitored in the hospital?

8. What is the protocol to investigate SEC PPH more than 3 weeks? – Blood investigations – clinical examination – ultra sound – consultation with O&G specialist.

9. For women at the age of 44 how long her uterus before involution? 2 weeks

10. Number of pads changed: before they called Dr. Lalitha to inform her of her HB level which was 8.9. Do you think in your opinion if they informed Dr. Lalitha that there was 6 ½ pads changed she would have discharged her any way. No (answered by a Gynecologist).

11. Entries by doctors in notes have lots of discrepancies.

12. 2 different Parthograph with different entries.

13. Blood lost in the operative notes, in the labour summary chart and discharge summary differs.

14. The indication for c-section differs in the 305 and the post operative review (case note 9 poor maternal effort).

15. Case note 37 post operative note blank.

16. The type of surgery on the case note 35 upper segment but case note 34 and case note 9 indicates lower segment.

Noted by a Gynecologist 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 form for surgery –

We found out during the trial that the signature on the consent form case note 26 defendants bundle of documents does not belong to Mr. Padan Labo. However it was allegedly singed by the Kam Agong. We the family member belief that the signature on the consent form does not belong to our mother and it has been falsified.

Defendant Case Notes:

Plaintiff Case Notes: