Swati Patel cannot stop thinking about what-ifs regarding the birth and death of her baby son last summer.
What if the scalp clip was not used to monitor her baby’s heart rate? What if the doctor had not performed a vacuum assisted delivery? What if the baby’s blood loss and the cut in her newborn’s head caused by the scalp clip were found sooner?
Although the Brampton mom, Ont., may never stop questioning, she could be able to help her family heal by offering an apology and a sense of responsibility for what happened to her son.
Patel said to CBC News, “I know that I am not going to get my baby back by doing all these activities.” “But I need justice to my baby. I need answers to my baby’s problems.”
Anant Patel was born in August 2021 at Brampton Civic Hospital. He died two days later. A post-mortem examination revealed that his death was due to complications from a blunt force head injury caused by birth. The head injury caused extensive bleeding between his scalp and skull and bleeding from the outside of his brain.
Patel stated, “Throughout my pregnancy he was totally healthy.” We try to meet the doctor who delivered our baby so that we can ask questions. But that has never happened.
Instead, Patel and Manish met with Brampton Civic Hospital management six months after their son’s death to review a quality-of-care committee review. The report did not mention the delivery physician and was mainly focused on possible issues with the baby’s post-birth care.
The meeting and review fell short of the accountability and apology the couple said they are looking for — both of which, a patient advocate says, are often hard to get in Canada given the fear of legal ramifications.
“It really shouldn’t be as hard as it is to get an apology,” said Kathleen Finlay, the Toronto-based CEO of the advocacy group Center for Patient Protection. “That’s all most people want. They aren’t looking for a lot of money from a large settlement.
Hospital offers condolences sincere
William Osler Health System, which runs Brampton Civic Hospital, told CBC News in a statement that it can’t provide specific details or comment because of its policies and to protect the family’s privacy and confidentiality.
“William Osler Health System expresses our sincere condolences to the family for their loss,” spokesperson Emma Murphy wrote.
We have a strong quality of care review process to evaluate the care given to patients. This includes engaging with families throughout the review and continuing support for them.
Two days after their baby died, a social worker from the hospital called the Patels and offered condolences and emotional support.
The quality of care report, reviewed by CBC News, says the vacuum-assisted delivery “may have contributed to subgaleal hemorrhage/subdural hematomas” — the only time a potential issue with the baby’s birth is mentioned. A vacuum-assisted delivery occurs when a doctor puts a small vacuum on the top of a baby’s head to use suction to help remove the newborn when the delivery isn’t progressing.
In January, Patels filed a complaint to the College of Physicians and Surgeons of Ontario. The Patels’ complaint will be heard by a committee in January to determine if disciplinary action against the doctor is warranted.
CBC News won’t name the doctor, as no professional misconduct claim has been made against them at the college.
Couple says they weren’t consulted
In their CPSO complaint, the couple allege that the doctor caused a scalp clip injury to their baby during labour and did not inform the neonatal intensive care unit (NICU) of the injury and blood loss; failed to obtain informed consent for a vacuum delivery; didn’t adequately perform the vacuum delivery leading to the baby’s injury; and failed to meet with the family to discuss what happened despite requests to do so.
CBC News reviewed hospital records and found notes and reports from doctors. According to those records, Swati Patel consented to vacuum-assisted delivery after being informed about the risks and benefits.
The doctor’s notes also state that “there was bleeding seen at the time of application of vacuum after removal of scalp clip — unclear if there was an abruption or blood was from vagina” and that the doctor was “careful not to pull hard” because of difficulty maintaining suction with the vacuum.
The Patels argue that they were never consulted about using the vacuum and asked that Brampton Civic Hospital make corrections to the doctor’s notes in their medical records — a request that was denied.
“Doctor took out scalp clip and [the doctor] Manish Patel explained that he put the vacuum on and tried to suction with it. “That was when I saw a lot more blood,” he said.
“Later, when I describe to Sick Kids hospital exactly what I saw,” said Dr. Sick Kids. “This blood was actually baby’s blood.”
According to the Patels, their baby was extremely pale at 3:18 a.m. when he was born. ET on Aug. 29, 2021, and, according to the records, had “poor respiratory effort,” so he was taken to the NICU.
A regional transport team couldn’t provide “timely” transportation of the baby to the Hospital for Sick Children in Toronto, so the NICU team tried to figure out what was wrong with the newborn while receiving direction by phone from Sick Kids until the transport team arrived, according to the quality care review.
The report goes on to say that early identification of a possible head bleed (later determined to be from the scalp clip in the post-mortem report) was also delayed because a head circumference measurement protocol was not followed as staff prioritized the baby’s breathing.
The quality committee recommended that the protocol be enforced again with front-line personnel and that there be monthly audits to verify compliance.
Parents say that parents are not able to find blood loss for several hours.
The couple says their baby’s care team didn’t determine that their son needed blood until several hours after he was born, when the specialized transportation team arrived, took over care and ordered a blood transfusion.
Swati Patel explained to CBC News that as soon as the blood was transplanted from the area where the scalp clip was inserted the blood began to flow out of the injury.
A post-mortem report confirmed that there was “subgaleal hemorhage during the transfer as well as bleeding scalp laceration. The latter resulted in the soaking several absorbent pads.”
Tests and scans at Sick Kids after the Patels’ son, Anant, was transferred revealed the extent of the irreversible brain damage to the baby boy, and how severe blood loss meant his heart was unable to pump enough blood to other parts of the body, causing his organs to start failing.
Anant was taken off a ventilator and died on Aug. 31 at Sick Kids. His mother said she’s still haunted by what took place and hopes that by speaking out, she can prevent the same thing from happening to others.
She stated, “I am unable to sleep at nights.” “I dream that my baby is in the hospital.”
More “healing solutions” are needed
Finlay, of the Center for Patient Protection, said an apology can be a strong healing tool for patients and their families — one that doesn’t necessarily put Canadian hospitals and doctors in legal jeopardy.
Finlay explained to CBC News that Ontario has had an Apology Act for over ten years. This ensures that no apology can be used in legal proceedings.
“It is not an admission to guilt but an admission of regret or sorrow.
Similar legislation is found in most other provinces and territories.
The centre has also advocated for hospitals to appoint chief compassion officers to ensure patients are listened to and dealt with in a way that considers their trauma.
“We really need to come up with much better, faster, simpler and more healing solutions so that families can move on,” Finlay said. It’s crucial.
The Patels for their part are still waiting for the outcome to their CPSO complaint.
Swati Patel stated, “I’ll try my best to do everything until I get justice.”