Suzan's baby Amir died at JHC in March this year. After much to-ing and fro-ing, I wrote this letter to the Minister and DG of Health. And the outcome is the attached article in The West Australian this morning:
" 28/06/2024
Minister Amber Jade Sanderson
Director General Shirley Bowen
Dear Minister and DG
As you may know from media reports I have been representing the family of Suzan Alhulow and Ali Al Khafaji. They are the couple who attended Joondalup Health Campus in March this year and over the next twenty four hours after their first attendance they lost their baby Amir.
We have now had two meetings with JHC Staff including XXXXX, Head of Obstetrics and Gynecology. The purpose of those meetings was twofold, firstly to let us know what process was to be followed and the second meeting was held after the post mortem in order to let us know the findings of that Post Mortem.
The meeting essentially provided us the Clinical findings of the cause of Amir’s death. Whilst we have had considerable trouble accepting the findings, we emphasise that we are not the medical and clinical experts to question or assess these findings. We will seek other professional assistance in so doing at the same time as we undertake legal proceedings against the system that has let us down so badly.
At the time of the presentation of those clinical findings we asked the question of the JHC Staff as to whether they were declaring this a “SAC 1 Incident”. Their categoric response was that a SAC 1 was exactly the same as the Clinical Review.
This is a highly contentious point. Our issue is not with the clinical reason for Amir’s death but more to determine if the procedures that were followed (or not followed) could have resulted in his death. And according to the department of health guidelines, SAC 1 incidents are “clinical incidents that have or could have (near miss) caused serious harm or death that is attributable to health care provision (or lack thereof) rather than the patient’s underlying condition or illness.”
This is exactly what we wish to determine – was it the provision or the lack thereof of health services that could have resulted in his death. The clinical investigation did not interview one single person who was on the ward that day. It only dealt with the clinical reasons for the child’s death.
There were a number of failures of procedure that happened on that day and into the evening. One of these was that Suzan asked from the very beginning of that day and on the checkup day 4 days prior that she wanted a Caesarian Section. She specifically ruled out a Balloon Catheter. Yet they ignored that and applied a Balloon Catheter.
Then at 4.00/4.30 on that afternoon, Suzan stated to the nurses and the midwife examining her that her waters had broken. She was soaked all down her legs and stated that to the professionals. They promptly ignored that statement and said that they “did not think so”.
Then she was placed in a delivery area at the back of the ward and ignored for some 4.5 hours. It was during this time that baby Amir died.
After the media attention was focused on these matters, JHC put out a press release that said that “There is no evidence that Ms Al Hulow’s waters broke at 4:30pm on 22 March 2024. In that scenario, care would have changed, and the balloon catheter would have been removed.”
Yet the Clinical Review did not speak to any of the ward professionals who were there on that day/night. And Suzan distinctly remembers saying to the staff member twice that her waters had broken.
Given that these matters go very much to the “process’ and not the clinical outcomes, I ask if it is possible/appropriate/feasible for the Minister or Director General to ask the JHC to institute a full independent SAC 1 inquiry and involve us in that process to determine exactly what transpired on that day that contributed or caused the death of Baby Amir.
Yours sincerely
Suresh Rajan"
Comments