Wrong surgery patient was not labeled, and appeared 'confused and disoriented'

KNH doctors who carried out controversial operation from left are Dr.Michael Magoha, Dr.Nelson Okedi, Dr.Dave Mangar, Dr.Hudson Nganga and Dr.Mose Moraa when they appeared before the health Committee at Continental House, Nairobi on March 14. [Photo by Boniface Okendo/Standard]

No one in the ward of the patients in the surgery mix-up at Kenyatta National Hospital had a name tag, a parliamentary committee was told yesterday.

“It is only after Health Cabinet Secretary Sicily Kariuki came to visit on learning of the incident that we found my brother with a tag,” Pauline Njeri, the sister of one of the patients involved in the mix-up, told the parliamentary Health Committee.

The committee, led by MP Sabina Chege, had invited the doctors who performed the procedure, tal, the two patients, Samuel Kimani and John Nderitu, and the facility’s board for a fact-finding mission.

Nderitu, 37, narrated his experience on February 19 through his sister, Njeri.

Njeri's testimony contradicts an earlier statement by the KNH management that Nderitu and all the patients in Ward Five A had name tags.

Njeri told the committee that on the day the CS visited the ward, visitors were chased out as the hospital staff put 'things in order' by changing the patient’s old gowns and dirty bed sheets, and scrubbing the floor.

“Even food, was served very well that day,” she added.

Mr Nderitu had been involved in an accident in Kahawa West on his way home on February 18.

Njeri said she wheeled Nderitu into the theatre at about 3pm on February 19 but to the family's surprise, they found him back in the ward about an hour later.

They were later told he would undergo the surgery later that night.

However when the time for the operation came, another patient, Samuel Kimani, 37, was instead wheeled to the operating room at 9.30pm under the guidance of theatre nurse Catherine Gakii.

Gakii was among the hospital staff who appeared before the committee.

According to the senior-most surgeon, Dr Michael Magoha, the mistake was found out after the patient’s skull had been opened.

Mary Wahome, the nurse who identified the patient for surgery, had a tough time explaining if the patient was tagged.

Ms Wahome said when she received information from her colleague that a patient was scheduled for theatre that night, she went to the male ward and called out his name.

“He responded. But he appeared confused somehow,” she said.

Wahome, who has worked at KNH for 23 years, admitted that when she was told that a patient scheduled for theatre, her colleague, Gideon Mwangi, did not physically identify the patient.

She also claimed that she was the one who tagged the patient when she was preparing him for surgery.

Hudson Ng’ang’a, a registrar who was part of the team that performed the surgery, said the patient was 'confused and disoriented at a Glasgow scale of 13 out of 15'.

“Patient was confused hence we could not depend on the patient to naturally identify himself,” he said.

Dr Ng’ang’a said when he realised that there was a mistake, he contacted his seniors, among them Dr Dave Mangar, a senior registrar, who joined the team. The surgery took six hours as the surgeon's tried to locate a blood clot.

Magoha, who was on call, was contacted at 3.30am and he too confirmed that all the paper work was in order and that the patient on the operating table was John Nderitu.

“At about 5.30am I made the decision to stop the surgery and have the patient undergo a CT scan,” he said.

The KNH board, led by its chairman, Mark Bor, was sent away less than 10 minutes into the sitting after only three of the 10 members showed up.

The MPs did not take kindly Bor’s explanation that the other seven members were ‘too busy attending to other issues’. Ms Chege told Mr Bor and his team to come today at least with six members.