It was the beginning of last year as a first baby at age 25 came to birth. Initially assessed all samples to be normal and no increased risk was deemed not to exist. After a few hours deteriorating certain test results and contractions subsided. After that, various measures were taken that did not give the desired results and during the early morning hours finally took a cesarean section. When the baby was lifeless, but they succeeded with their resuscitation attempts. After one day lead the child.
University Hospital Lex Maria reported the incident and notes that the reason why the mistake was made, among other things, was unclear routines for “unusually” high load on the women’s clinic during the call time , unclear communication between the on-call doctor and a lack of risk assessment in connection with the engagement.
Inspectorate for health and care (IVO) assesses deficiencies as serious and affirms “that the birth of more points not dealt with under science and proven experience “.
To avoid that similar events occur, the guidelines for what happens in the clinic when there is high load clarified, bakjourens and förlossningskoordinatorns information be clarified, Education strengthened, and a number of additional measures.
IVO concludes hereby file and will follow up to the hospital vidtaget proposed measures later in the year.
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