Yap Sook Lin
16 Jalan SS 3 / 26A
47300 Petaling Jaya
Selangor Darul Ehsan
Malaysia
th
17
June 2013
subsequently had a full course of
chemotherapy followed by radiotherapy as
advised. Mum was being treated in a
specialist centre, UMSC, and subsequently
transferred to the government hospital
UMMC for follow up. Her last radiotherapy
was on 6th April 2012. Since then, she had
seen the doctor on 4th Sept 12, 4th Dec 12
and 8th Jan 13. Its indicated in her
appointment card that she had blood test
th
done on 30 Nov 12. These tests were
immediate treatment of chemotherapy. The
doctor who gave my family the bad news did
not answer or could not answer the many
questions they had. My sister wanted to
know how did it get so advanced, and why
was it not picked up earlier or any follow-up
cancer markers done after mum had
completed her radiotherapy. Is this our fault
for not ensuring the hospital is carefully
monitoring my mum? She had attended
every appointment in the hospital that was
cancer was discovered, they told us to go
away for a week to decide what we wanted
to do. How can anyone make decisions when
they are not fully informed of the choices
available? My mum clearly did not have time
in her hands to wait for a week. Aren't
doctors meant to treat patients? It appears
that we were begging for help instead.
radiotherapy sessions on 20th May 2013. She
started to have some improvement with
reduced swelling in her left arm on the third
session. However, progress was slow and she
would take one step forward with three steps
backward. She was not able to eat, and her
appetite had significantly decreased. Over
the days, mum seem to show little
improvement. Both my brother and myself
rushed home from abroad to care for her.
completed a procedure where she had
250mls of fluid drained from her lungs. She
was subsequently taken for radiotherapy. The
doctor had met us at the corridor to update
us on mum’s progress. The events that
followed in this private hospital had shocked
me.
to him a few times, trying to call someone as
the session began. The phone appear to be
engaged or no one responded as he kept
dialling. I noticed my mum in distress again
from the screen, and this time, she is
struggling to get up. The radiographer
discontinued the session and went into the
room again. I decided to go in with him as I
could see mum struggling. When I saw my
mum, she was dusky in colour and was full of
sweat on her forehead. She was tachyapnoea
failed her duty of care. She had not checked
the oxygen cylinder when I had alerted her
that it looked empty. She had not calculated /
predicted if the cylinder would be sufficient
for my mum’s entire radiotherapy session.
She had disconnected the saturation probe
and turned the monitor off on a patient she
know who is oxygen dependent and just had
pleural drainage. She had walked away from
the radiotherapy room with her colleague
and did not stay to observe my mum or
mum’s medical consultant, Dr. Lim YC. I had
requested to see all my mum’s scans that
was previously done. Dr. Fuad showed me,
my brother and my dad and carefully
explained the metastases seen in the scans
and what it all meant. Mum’s cancer was
advanced. I could see on the chest x-ray the
streaks of white patches on her both her
lower lobes. This was a concern, and would
explain the oxygen requirement she is
having. We were saddened with the news.
mum receive the Combivent that is supposed
to help her to breathe better if she
discontinue it? She was silent and did not
react to the dropping saturation that was
indicated on the saturation monitor. It was
sitting in low 80%. I advised her to increase
the flow of oxygen quickly. She did so but the
nebuliser was unable to hold such a high
flow. The Combivent completed quickly due
to the increased flow, and I requested for her
to put my mum back on the humidified
admitted in hospital since Monday. My sister
had done the day shifts, and my dad doing
the night shifts. Our family had made plans
for me to do the night shift. My brother
stayed in the afternoon with my mum until I
returned in the evening.
From this moment onwards, the event that
follows in this private hospital has marked
me for the rest of my life.
(NGT) fed. Due to her respiratory distress, it
was unsafe for her to have anything orally. It
was also difficult for her to eat anything
orally while she is receiving facial oxygen at
15L/min. The dietician had prescribed the
necessary nutrition my mum required in
24hours. This was delivered 3-6 hourly.
stethoscope. She then aspirated the air, and
subsequently bolus fed my mum via gravity.
Mum’s medication were crushed, and this
was diluted with some milk, and given via the
NGT. Her feeding syringes were washed and
left by her bedside table for next use.
to please put on a pair of gloves. Tip of
mum’s winged insfusion set which access’s
her chemo port was not a needle-free valve,
so they removed the cap, cleaned it, left the
cap on the tray, gave the medication, and
replaced with the same cap. There was no
handwashing before or after procedure. The
sink was located in the entrance / exit of the
room. As I corrected this nurse, the nurses
who came for the following next doses were
wearing gloves! An intravenous access
getting breathless. I kept having to reassure
her, hold her hand as the saturation monitor
would be alarming. None of the nurses came
in to check on my mum when the monitor is
alarming in the night. I have had to replace
her finger probe a few times as it kept falling
off her finger as she moves in the night.
changed at 12 midnight. Her diaper was dry!
Mum was in distress again as she was stirred
to have her diaper changed, and the lights
were turned on. She started to desaturate.
They had rang Dr. Lim, who later requested
to speak to me. Mum had been stable all
night, and that was what I reported to him.
The only time she was in distress was when
she was trying to talk.
requested the nurse not to wake mum up as I
had just settled her and she was
comfortable. However, mum stirred and
woke up during the feeding. She soon settled
back to rest again. Mum also had another
course of antibiotic via her chemo port.
room and calling me to speak to a doctor on
the phone. I told the nurse that the doctor
should be here, and not on the phone and
ignored her. Mum was in respiratory distress,
and her saturation had just increased to 90%
again but she was making huge respiratory
effort. The nurse came again , insisting I go to
the phone to talk to the doctor, and
promised that she would stay with my mum
while I was away. I felt reassured and ran to
the phone. I remember speaking to the
trolley. They were opening each drawer of
the trolley looking for things. I saw a nurse
holding an airway and pointed out to her to
pass it to me. By this time, mum was loosing
consciousness. I inserted the airway to
prevent mum’s tongue from sliding back
obstructing her airway. Mum was clearly in
distress and turning blue. Her saturations
were dropping to 70%. There must have been
at least 6 nurses in the room now, and they
started to flatten mum’s bed and one started
of air while another nurse was performing
the chest compression, both at the same
time. I had to tell the nurse who was doing
the chest compression to start counting so
the nurse who is bagging knows when to give
the breath.
connected to anything. I corrected her
immediately and she called out for another
nurses to pass her the tubing from the
resuscitation trolley and another nurse
quickly changed the connector to ensure
mum was receiving oxygen while being
bagged.
I notice another nurse plugging in suction
apparatus on the wall while all this was going
on.
got the ECG leads but did not know where to
place it on my mum’s chest! I had to tell
them. The leads kept falling off while the
compression was in progress, and she kept
sticking it back on.
one. They looked at each other. I reached out
to the syringe by my mum’s bedside table
that the nurses had left previously. I started
to aspirate my mum’s NGT, and got all the
stomach contents out and left her NGT on
free drainage instructing the nurses not to
close it.
I called out for adrenaline to be prepared and
saline flush and ordered the nurse to be
ready to give it using mum’s chemo access
port.
flushed with saline. CPR continued for
another two more cycles. I requested for the
team to stop CPR again to assess the heart
rate. The ECG leads kept falling off my mum’s
chest. I made a quick listen to her heart with
the stestoscope, and confirmed that her
heart rate was undetectable. I ordered CPR
to continue as long as mum’s heart rate was
less than 100 beats per minute.
I ordered the second dose of adrenaline to
be prepared and given.
was busy putting on blood pressure cuff on
my mum’s right arm. She was clearly in the
way. I instructed her to remove the cuff as it
was not a priority to monitor her blood
pressure at this point.
and bluish. She is still showing no signs of life
or making any spontaneous respiratory effort
despite the second adrenaline given and
continuous CPR.
two nurses trying to work the defibrillator.
Mum had minimum heart rate of probably
20bpm. There had been no improvement.
Mum had been hypoxic for at least 10mins, if
not more. I requested for the nurses to
discontinue CPR.
I sat holding my mum in my arms, and knew
she had passed away despite everything.
oxygen. The Director of hospital confirmed
this. I was also notified by the Director of
hospital that there was a doctor present
during the resuscitation of my mum in the
morning of her death. However, the medical
doctor had thought I was the doctor instead.
I was totally unaware that there was a
medical doctor present in the room. He / She
had not identified herself to me. The only
doctor I saw in the morning was a doctor
who came to certify my mum’s death at
retrained. I received a telephone call on 11th
June from the Director himself, inviting me
back to the hospital. However, I have turned
the offer down as this drill and exercises
should have been practiced frequently in the
hospital, and not done because an incident
had occurred due to their negligence and
failure to monitor the competency of their
staff.
the mistakes, the poor performance, and lack
of competence by the team. I wonder how
many others have suffered, and have
experienced what I have experienced, and
not being able to voice their complain for the
fact that they are ignorant, or they feel they
could not challenge a large well known
private hospital. Like them, I will not have the
sufficient funds available to fight such a large
hospital, but I do not wish for anyone else to
ever have to go through what my mum went
practicing evidence based practice. Aseptic
technique should be used on all intravenous
access and hand washing is the best way in
prevention of infection. My nephew who is 5
years old knows that. Mum is immuno
compromised. Acquiring septicaemia from a
line infection would be detrimental to her.
be disconnected and deprived of oxygen
while tubings are being changed. Access to
suction should always be available, not just in
emergency. You cannot predict when it is
needed. This is a small price to pay from the
hospital to ensure patient safety. Emergency
equipments should always be available by
the bedside and checked daily.
highlighted the unreliability of methods such
as the ‘whoosh’ test and litmus paper. The
‘whoosh’ test was being practiced by the
nurses on my mum. A pH indicator should
have been used instead – International
Journal Evidence Based Healthcare 2011 Mar
9(1); 51-60. I do question if the nurses can
hear the 'whoosh' when mum's facial oxygen
at 15l/min is probably louder than the
surrounding noises.
be crushed and given to mum via the NGT. It
is enteric coated and should be swallowed
whole so it can slowly dissolve. Why did she
have to tell the nurses this? They should
know what they are giving and how to
administer it.
nurses. They should be placed nearest to
where the nurses are in the ward – nursing
station. This is not a choice of being in a
single room or double room or 4 bedded
room. Its where the patient can best be
cared for. Nurses should not be doing routine
observations or TPR at fixed times of the day
(6am). Nurses should be competent, caring,
compassionate and ensuring patient safety.
They should be knowledgable and act as an
advocate for their patients. They should be
the medical team themselves. The relative
are simply informed of the decision. The
nurses should be able to assess their patient
and discuss the plan of action with the
Consultant accordingly. How can anyone
assess a patient over the phone and make
decisions when not seeing the patient? Is this
practiced frequently
she might as well not be there. I am terribly
disappointed at the performance of
Gleneagles and be so let down by them. I
hope this event would raise sufficent
awareness in the future and that nursing
schools would review their curriculum and
nursing training, and hospitals would review
and update their protocols. The health care
system needs to change. How many more
will have to suffer and die before changes
take place? One is enough .. more than
Written by:
Sook Lin Yap