Cabrini Hospital upgrades emergency-call system after mother’s cry for help goes unheard

by admin on July 13th, 2018

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Stephanie and Thomas David at home with daughter Luella. Photo: Paul Jeffers Ms David was recovering from a caesarean and epidural and was unable to stand up to help her newborn daughter. Photo: Paul Jeffers
Nanjing Night Net

One of Melbourne’s top private hospitals has upgraded its emergency nurse-paging system after staff failed to respond to a bedridden mother whose newborn baby had stopped breathing.

Cabrini Hospital in Malvern described as “less than optimal” the mother’s experience in January this year, when she desperately tried to alert staff to her daughter’s deteriorating condition hours after the baby was born.

Stephanie David was recovering from an epidural and caesarean and unable to stand up to help her daughter, Luella, when the child started foaming at the mouth in the cot next to her hospital bed.

In her complaint letter to Cabrini, Ms David said she repeatedly pressed the nurse-call button for a number of minutes and then started screaming for help because Luella turned blue but was out of her reach.

The husband of another woman on the ward heard her cries and rushed into the room, picking up the newborn and running to find medical staff.

The hospital’s incident report shows staff called a code pink – a paediatric emergency – and the baby was taken to the special-care nursery, where she had to be resuscitated.

“She had an apnoeic​ episode, which is not uncommon in newborns, but it became an emergency because I wasn’t heard,” the Brighton mother-of-three said.

“I knew we were in trouble because I was physically unable to get out of the bed and after I started pressing the buzzer nothing was happening.

“I’m crying and yelling for help at the top of my lungs and this stranger appears and amazingly picks Luella up and runs her to the nursery. The next thing, I hear them call a code on her, all the alarms go off, I have no idea what has happened to her, if she’s alive or dead.”

Correspondence from the hospital shows the midwives could not hear the call system because they were in other patients’ rooms at the time and were unaware of the unfolding medical emergency.

In a letter to the David family in February, the hospital apologised and said its nurse-call system did not have an emergency function, meaning there was no distinction between a routine request for assistance in a room and an urgent request for help.

Cabrini said the system would be modified immediately.

“Please be assured that this matter has been taken very seriously and that corrective action is being undertaken to minimise the chances of an incident such as this happening again,” it said.

The hospital also admitted it had failed to provide Ms David and her husband, Thomas, with a complete orientation to the room.

She said she was never told about an emergency button on the wall or given the number to call midwives directly from the phone. The button and the phone were also out of her reach.

Ms David said she was traumatised by the experience and that doctors could not rule out the possibility  Luella’s health and development had been compromised in the days immediately afterwards.

She was refunded for her stay in Cabrini and all fees for treatment in the special-care nursery were also waived.

The hospital said the refund was granted “due to your less than optimal experience, as a gesture of goodwill”.

Cabrini Malvern executive director Simon Woods last week apologised for the distress the incident caused the David family and said the case prompted an upgrade of its nurse-call system in the maternity unit.

“We have enhanced our nurse-call system with another feature, so that when a patient presses the call bell three times, it converts immediately to staff-assist call, both audibly and visibly,” Dr Woods said.

A staff-assist call raises the attention of all employees in the ward.

“Recently we checked this system and are confident it is working as it should. This enhancement will provide an increased level of comfort to our patients.”

Practices and procedures at Victorian hospitals have come under intense scrutiny in recent months amid rising concerns about avoidable baby deaths. A spate of potentially avoidable baby deaths was identified at the Bacchus Marsh and Melton Regional Hospital between 2001 and 2013.

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