Eight months of torture caused the death of 8-yr old Gabriel Fernandez. Kira Dixon Johnson bled to death shortly after giving birth because her husbandâ€™s pleas and concern were ignored. A busy clinic missed an important risk factor of first-time mother, Amber Rose Isaac who hemorrhaged to death a late diagnosed HELLP Syndrome immediately after her son was delivered.Â What do these tragedies have in common? They were all victims of system failures.
Are you tired of witnessing these disasters because I am. As an OBGYN physician for over 30 years and a former social worker, here are my proposals for change regarding missed diagnosis of child abuse and OB risk factors:
- Â Â When a social worker receives a suspected child abuse case, he or she should be mandated to take pictures of the child to document well-being or abuse. Gabrielâ€™s mother consistently hid him from social workers in a cabinet.
- A social worker should be required to speak with said child and not merely take a report from the parents as was the case with Gabriel.
- A volunteer corps of retired social workers and pediatricians should be activated to assist overworked child abuse workers and help manage more complex cases.
- A â€œsecond opinionâ€ model should be activated that would provide independent risk assessments, by board certified ob-gyn physicians if a pregnant mom has concerns about her present management
- â€œReal-timeâ€ assessment of a fetal monitor strip to screen for potential and unrecognized fetal distress by an independent board-certified ob-gyn physician that can be done remotely while the patient is in labor
- All hospitals should be mandated by the Joint Commission to participate in their state Perinatal Quality Collaboratives which include monthly patient simulations regarding obstetrical emergencies and use â€œpatient bundles.â€ Failure to comply would mean loss of hospital accreditation and state funding.
The greatest gift we can give the families of the deceased is to prevent these mistakes from recurring. Â I have shared some of my ideas and would love to hear yours. Letâ€™s turn future scary challenges into happy endings.
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