Baby Kimorah Leslie's death was needless and preventable and the community outrage that accompanied her passing forced the Ministry of Health to launch an investigation. Its work was quick, and its results were announced today. Who did it indict for incompetence or dereliction of duty? Alfonso Noble found out.
Alfonso Noble Reporting,
Accompanied by director of health services Dr. Jorge Polanco and CEO in the Ministry of Health Margaret Ventura, today Minister of Health Joe Coye made public the findings of the investigation into the death of baby Kimorah Leslie.
Hon. Jose Coye, Minister of Health
"It is quite evident that a neurosurgeon was not available at the time when the admission was first made on April 21st. That is the admission during that period and that is where the break down took place."
Because of that break down, the investigative team recommends that Dr. Geovanni Lara be investigated for not responding to a call to come back to work.
Hon. Jose Coye,
"He was in a contract of employment with the hospital and yes he was on leave but he was informed and he was directed to come back from leave to do the evaluation and to administer the care."
Alfonso Noble,
At one point was he informed?
Hon. Jose Coye,
"…and he did not."
Alfonso Noble,
And what time was Dr. Lara informed that he ought to come in to treat the child?
Dr. Jorge Polanco,
"He was informed a few days before the case of Kimorah Leslie. KHMH sent a message and the correspondence and he did not return."
Alfonso Noble,
Did he receive the correspondence?
Dr. Jorge Polanco,
"There is evidence where there was a telephone conversation in regards to that correspondence. We have that evidence."
Alfonso Noble,
Had there been a second neurosurgeon would there have been a need to call in a doctor that was on leave?
Dr. Jorge Polanco,
"Definitely not but he was the only one employed at that time."
Now the Belize Medical Council is being encouraged to investigate Lara's conduct in this case and that no employment agreement be entered into with him until such investigation is completed. As for the KHMH's role in the death, Director of Health Services Dr. Jorge Polanco's team has determined that everything that could have been done was done to try to save Baby Kimorah's life.
Dr. Jorge Polanco,
"The child came in and the child was managed at the Accident and Emergency room by the health professionals who were there. We looked at a chronology of events from when that child came in to when she died. We looked at all the details in regards to nursing care, in regards to administration of the drugs, in regards to the recording and everything and we also looked at the information coming from the pathologist and we also looked at the death certificate. When we looked at that, what we concluded from there was that care that the baby got during that time she was at KHMH was within acceptable standards."
But even with acceptable standards the two year old's life could not be saved and now up for consideration is the KHMH's capacity to provide secondary and tertiary level care.
Dr. Jorge Polanco,
"We had control over one neurosurgeon who was on leave. We asked him to come back. If he would have come back, or didn't come back, how would that have contributed or what it changed, I could not tell you save the child's life. I am not reaching to any conclusion but that explains what you are making reference to. That poor communication/administrative issues and this is what the Minister made reference to. We are aware and that would have been step two. Right now we will see how far can we go. Will we go beyond our means, will we limit it, will we go back. That is a question that can only be answered after we make a detailed analysis of how far we can go. One thing is for sure, at that time we did not have a neurosurgeon. That is the reality and we had made public that we were suspending our neurological services. What can we do? We didn't have him, that's a reality."
Hon. Jose Coye,
"The KHMH I hope would not been seen as the health system but is seen as a facility in the health system that is responsible for the curative interventions at the highest level that we can provide in the public sector. KHMH has become like the St. Christopher in a sense. No one is being turned away but does it has the capacity to deliver the service at a high standard or at a reasonable standard given the limited resources. I would ask that we look at this issue in the context of the health system in general, limited resources to meet almost unlimited demands and how do we cope with it. I think because the investigation was centered on the finding of facts and then to look at those facts to see whether they resulted in any breaches of the contracts etc., I feel like the investigation has gone sufficient for us to pause, take stock, and make the next move. One clearly is to look at where we can improve within the hospital and as I cited earlier, in particular we need to pause to see what are the services we can really provide with our limited resources."
Limited resources seemed to be the only explanation that the Minister could have come up with to explain the loss of Kimorah, the question now remains if such a scenario could repeat itself.
