TOPIC NO.

3
A system failure resulting in death
This example highlights how pressurized environments may fail to provide basic standards of care.

Mrs. Brown was a 50-year-old administrative assistant working in the supply department of a hospital. She
was overweight. She slipped in her garden while getting the newspaper and struck her leg on a garden tap.
She suffered a fracture of her fibula and was admitted to hospital because it was swollen and painful and
required reduction. The procedure was delayed because the operating theatre was busy and her injury
was a relatively minor one. The orthopaedic ward was full and so she was placed in a medical ward.
Two days later, the fracture was reduced and her leg was put in plaster. When she got up to go home she
collapsed and died. At autopsy it was found that she had suffered a massive pulmonary embolus. At no
stage was heparin prescribed for the prevention of deep vein thrombosis or any other preventive measures.
Her husband was told that she had died from a clot on the lung which had formed in her leg as a result
of swelling and trauma. The lack of preventive measures was not mentioned.

Activities
– Construct a flowchart of Mrs Brown’s admission from her accident to her death.
– Identify all the health professionals (and their responsibility) who may have been involved in her care and
treatment
– What are the possible factors that may have contributed to her death?

TOPIC # 7

Use quality-improvement tools and techniques in your own personal self-improvement projects.

TOPIC # 8
Giving birth at home
This case describes incorporating important family members in health-care decisions.

Marie was pregnant with her second child. Her first child was born in the local hospital without any
complications. During this pregnancy, antenatal care had been provided by a midwife. All the check-ups
indicated a healthy pregnancy and, at 36 weeks, Marie and her midwife discussed the birthing plan.
Marie said she would like a home birth, but her husband felt a bit uncertain about it.
Her midwife explained that home birth was an option as everything was OK with the pregnancy and Marie
had experienced an uncomplicated birth the first time.
When Marie reached 39 weeks of pregnancy, her contractions began and she called her midwife, who
visited her at home. The birth progressed quickly and within two hours she was fully dilated. When Marie
started to push, the midwife heard that the baby’s heart rate was dropping. She moved Marie onto her left
side and asked her not to push. Within five minutes, the heart rate had improved and the head of the baby
was crowning. One minute later, a healthy baby girl was born. Mother and baby were doing well in the first
hours after birth.
The next day, the midwife visited Marie and her husband at home. They talked about the birth. Marie’s
husband said he found the midwife very experienced, but he was still shaken up by what had happened
with the baby’s heart rate. He had not wanted a home birth.

Questions
– How could the midwife had ensured and checked Marie was well informed about a home birth?
– How can relatives (in this example the husband) be involved in choices and decisions?
– What would have been a good way for the midwife to address the husband’s concerns?