Media statement by Gauteng MEC for Health and Social Development, Qedani Mahlangu, on the findings of the investigating team into the death of babies at Charlotte Maxeke Johannesburg Academic hospital, July 21 2010

Following the tragic events at the Charlotte Maxeke Johannesburg Academic hospital in which six babies died on 18 and 19 May 2010, I appointed an independent team of experts to probe the circumstances surrounding this unfortunate incident.

The eight member team which comprised of retired and practising experts in child health was tasked to analyse the causes of deaths as well as to make recommendations to prevent similar incidents taking place in future. The following persons were part of the team:

• Professor Dankwart Wittenberg, Former Head of Paediatrics at Steve Biko hospital, (Chair)
• Professor Sithembiso Velaphi (Head of Neonatology at Chris Hani Baragwanath hospital)
• Professor Keith Bolton (Head of Paediatrics at Rahima Moosa Mother and Child hospital)
• Professor Yusuf Veriava (Physician at Wits University)
• Ms Cecil Pretorius (Infection control specialist at Steve Biko hospital)
• Mrs Thoko Moloko (Member of the Gauteng nurse managers forum)
• Ms Ethel Lesolang (Member of the Retired nurses forum)
• Dr Lesley Bamford (Paediatrician from the National Department of Health)

The team started its work immediately and they submitted the report to me. The team concluded that the babies were infected by norovirus, a relatively common gastrointestinal virus that is spread by contaminated hands, water, or food.

The response of the hospital to the outbreak of vomiting and diarrhoea among the babies on 16 May was found to have been adequate. No specific acts of negligence in relation to the care or treatment of individual patients were identified.

After analysing case notes relating to the babies who died at the hospital, senior neonatologists came to the following specific findings:

• In all the six babies, the cause of death appears to be related to a highly virulent outbreak of gastroenteritis in the premature baby unit.
• All babies were high risk cases with a birth weight less than 1500 grams, although most seemed to be progressing well before the outbreak.
• Invasive Klebsiella infection (as identified by blood culture) was not prominent in the cases that died and proven bacterial septicaemia was an inconsistent finding.
• HIV exposure was not a prominent feature. All babies had received formula feeds instead of breast milk.
• The general level of medical care was good. The onset and progression of disease from well to death was extremely rapid making individual management difficult. No individual cases seemed to show any specific negligent medical care. All babies were treated with a range of antibiotics.
• Records kept by medical and nursing staff were excellent
• All cases had been included in the list of diarrhoea cases occurring in ward 177 on 16 May.

Overcrowding was identified as a major contributory factor, however this is not limited to Charlotte Maxeke but it is a challenge faced by most of the public health institutions in the province. This matter is receiving our utmost attention and we are working with the private sector to improve the situation.

Overcrowding leads to:

• less space between baby cribs or incubators which increases the risk of infection
• insufficient staff relative to the norms and requirements for safe care
• more babies to be cared for by each nurse which increase the risk of mistakes in standard of care
• more mothers and outside visitors enter into the available space.

The team also found the following deficiencies regarding the facility and resources:

• lack of routine supplies such as roller towels or antiseptic sprays; without towels, adequate hand washing cannot take place
• insufficient routine equipment such as thermometers, dextrometers, oximeters
• lack of locker facilities and change rooms for parents and staff which results in parent jackets and bags being placed on shelves
• structural challenges in the design of ventilation system and positioning wash basin.

To address these factors we have taken a decision that from 1 July, all hospital chief executive officers have to procure infection control equipment directly without going through the Gauteng Shared Service Centre. This will make the procurement of infection control equipment quick and save lives.

The following recommendations were made by the investigating team:

Hospital management should be supported to respond to the issues identified in the report.

• Hospital management of all big hospitals should be supported to encouraged the infection control, and quality assurance units to be pro-actively involved in promoting safe practices and continuing staff training in the application of routine standard operating procedures, where this is not yet routine.
• The committee also recommended that a neonatal advisory task team comprising perhaps two or three neonatologists and two or three neonatal nurses be established to advise the Health Department on issues of neonatal care in this province.

In an effort to address the issues raised in the report the department has employed 30 retired nurses who will go around our health facilities to strengthen infection control measures.

Infection control nurses in hospitals are being empowered to intervene and enforce infection control measures such as regular washing of hands.

While the deaths are not linked to HIV and AIDS, the department believes that the implementation of the new HIV and AIDS protocols that require HIV positive mothers be initiated on prevention of mother to child transmission programme at 14 weeks will assist in reducing the number babies born with low birth weight.

However with 120 000 children born in the province every year, our facilities will continue to experience pressure. We are however determined that we must gradually build our capacity to achieve a norm of 1 nurse to five babies in our neonatal units.

The number of students trained in advanced midwifery, critical and neonatal care will be increased by 100 annually from this year in an effort to improve our capacity.

I would like to thank the team for its sterling work and want to assure the public that the department is committed to deliver quality health for the citizens of Gauteng.

Statement issued by Gauteng Health and Social Development, July 21 2010

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