Medical Negligence In Nigeria: When Hospitals Kill

Welcome to part one of Radiant Health’s special three-part series on medical negligence in Nigeria. This week’s article, “When Hospitals Kill,” focuses on the underlying causes – and tragic consequences – of medical negligence.

On October 9, 2012, Lanre Amoo-Onidundu was shot in the leg by daredevil armed robbers who attacked him as he stepped out of a bank in the Ilupeju area of Lagos. They made away with the 2.6 million naira that Amoo-Onidundu, an administrative officer, had gone to the bank to cash for the organization he worked with, leaving him in a pool of his own blood. Fortunately, some bystanders who had fled during the attack returned to rush the young man to the nearby Gbagada General Hospital. Amoo-Onidundu was thankful for the help of the good Nigerians, and even more thankful when he saw the hospital, believing it was not his day to die after all. Little did he know that he was about to enter a place that would change his life forever.

Immediately upon arriving at the hospital, Amoo-Onidundu got his first taste of what was to come. He was told that there was no free bed, so he was “admitted” to the bare floor of the emergency section of the government hospital. But this was just the beginning of his ordeal. He lay on the floor for hours, bleeding, without receiving any treatment, not even basic first aid. After several hours, he was finally placed on a gurney, and a medical doctor examined him there in the emergency room.

The doctor felt the area around the gunshot wound to see if there were any bullet fragments in the leg. Then he gave Amoo-Onidundu an injection to help relieve his pain, and lacking any proper dressing, wrapped the wounded leg with brown carton paper. That was all the first aid he would receive at that time, though they did eventually extract the bullet, which was lodged in his thigh slightly above the knee, and sewed him up: job complete. The medical staff did not examine his injury with a CT scan or imaging technology to verify the extent of the damage or what to fix. Amoo-Onidundu remained at the hospital for days, receiving no treatment other than the usual daily dressing of his gunshot wound. The condition of his leg deteriorated.

Amoo-Onidundu’s imaging result

Finally, on October 25, sixteen days after he was admitted to the General Hospital, Amoo-Onidundu’s relatives moved him to a private hospital in Abule-Egba, another area of Lagos. Here a CT scan confirmed that his attackers’ bullet had pierced his right thigh just above the knee. The scan also showed that the bullet had broken the thigh bone and severed the main femoral artery, cutting off the blood supply to the lower part of the leg. The doctors at the general hospital would have seen this had they ordered a CT scan, and they would have had a fighting chance to save the leg.

But now it was too late. The blood supply to the lower part of the leg had been cut off for too long, causing tissue death. The wound was also infected, so the leg had to be amputated before the infection spread to other parts of his body. Today Amoo-Onidundu lives in Germany, his prosthetic limb a constant reminder of his misadventure at the Gbagada General Hospital. He pays the price for medical negligence every day.

Juwura’s Story

Juwura Amoo-Onidundu

On June 7, 2011, Juwura Amoo-Onidundu [footnote] Juwura is Lanre’s sister-in-law [/footnote] entered the maternity ward of the University College Hospital in Ibadan to deliver her second baby by elective caesarean section, after having suffered complications during her prior delivery. According to her husband, Banji, she was wheeled into the operating theatre at 9:00 a.m., and the baby was brought out of the theatre around noon. Juwura was wheeled out at 3:00 p.m. The average caesarean section takes about 45 minutes, but Juwura’s C-section was not average: her left fallopian tube had been punctured and subsequently removed during the procedure.

After the operation, Juwura’s packed cell volume (PCV) dropped significantly, indicating severe blood loss. She was given a blood transfusion, but instead of stabilizing, her PCV kept dropping. A normal PCV ranges from 34 to 38; Juwura’s plummeted from 37 before surgery to 22 after surgery. Even after the transfusion, her PCV fell to 20, then to 17. Finally, she went into shock. She had been transfused with the wrong blood type. Juwura Amoo-Onidundu died on June 8, 2011, leaving behind her newborn baby, her two-year-old child and her husband.

The Negligence Epidemic

A study in the current issue of the Journal of Patient Safety suggests that each year between 210,000 and 440,000 American patients who go to the hospital for care suffer some type of preventable harm that contributes to their death, making medical errors the third-leading cause of death in America after heart disease and cancer. If America suffers from this degree of medical negligence, even with its more highly developed and sophisticated health care system, then it follows that Nigeria, with its weaker health care infrastructure and under reporting of medical negligence cases, is even worse off. And while there is no incontrovertible data on the actual number of medical negligence cases in Nigerian hospitals, patients and medical practitioners alike acknowledge that number to be very high.

There are many reasons that medical negligence occurs in hospitals. Dr. Biodun Ogungbo, a neurosurgeon who also writes a medical column for a national newspaper, believes that some of these factors are cultural in nature. The Abuja-based doctor says that medical negligence is rife in Nigeria because of the impunity in the society itself, which he says is also manifest in many Nigerian hospitals. “In our society, people do things that they don’t get punished for,” he observed, adding, “If they were punished for it – once, twice – all these kinds of things would stop, but because there is no punishment, it will continue to happen.”

Juwura’s husband, Banji Amoo-Onidundu, agrees: “It [the medical system] is structured in a way to build mediocrities and to build people that are arrogant and bigger than the job. They do whatever they like and they get away with it. That is what has destroyed the fabric of our society.” Put simply, medical negligence thrives in a society where medical personnel are not held responsible for their actions. And this lack of accountability fits in all too well with the image of medical doctors as infallible.

Medical Law Lawyer, Laolu Osanyin

Laolu Osanyin, a Lagos-based lawyer who specializes in medical law, suggests that this myth of infallibility lies at the base of the problem. Osanyin believes that the national medical negligence problem can be connected to the way that many Nigerians perceive medical doctors and “situate” the responsibility for medical harm. “Historically, the Nigerian doctor was equated to the status of a healer or a priest who could do no wrong,” says Osanyin. “Those days, if anything untoward occurred in the treatment of a patient, the doctor was usually the last person to be held accountable. The Nigerian patient or their families will locate someone in the village who they can hold responsible for the problem; if they find no one to drop the problem at their doorstep, they say it is destiny.”

“Not Enough Anything”

All of the blame for incidences of medical negligence cannot be laid solely at culture’s door. The dearth of resources in many Nigerian hospitals – especially the government-owned ones, where the doctor-to-patient ratio is extremely high – is also complicit in this problem. “In some parts of the world, yearly a neurosurgeon will treat about 5,000 people. In Nigeria, one neurosurgeon treats about 5 million people,” says Dr. Ogungbo, exaggerating to drive home his point. “Many public hospitals are overwhelmed, just overwhelmed. Not enough doctors. Not enough nurses. Not enough drugs. Not enough anything,” he says, exasperated.

RELATED: The New Nigerian Health Bill And What It Means To You

According to the Nigerian Medical Association website, there are over 40,000 medical doctors in Nigeria serving a population of about 160 million Nigerians. Douglas Okor, a Nigerian-trained neurosurgeon in Britain, says, “There is an estimated 1 doctor per 5,000 Nigerians, compared to 1 doctor per 242 in the UK. Most of these medics in Nigeria are in teaching hospitals, federal medical centres and general hospitals in the cities. A rough estimate of the number of medical doctors in a teaching hospital like the University of Benin Teaching Hospital, Benin City, is 600-700.” This high doctor-to-patient ratio affects the number of cases a doctor can take on, how quickly he can respond to them, and the quality of the services rendered.

Laolu Osanyin agrees, pointing to a shortage of both resources and personnel: “There is a lack of major facilities. There are, for instance, ten people waiting to be operated on. Meanwhile, there is only one theatre which takes one patient at a time. What will the doctor do?” Often doctors will select the most urgent cases, leaving the other patients to wait for longer periods. Osanyin says that the shortage of personnel in most hospitals leaves room for medical negligence to occur. “A doctor would tell you that between 10:00 a.m. and 12:00 midnight, he has done 14 caesarean sections. Definitely there will be a margin for error. So at some point, he will forget something; at some point in time, he will be tired.”

Dr. Ogungbo once worked at the National Hospital, Abuja, which is Nigeria’s premier government hospital. “There were times when someone would rush from the ICU to the ward and say, ‘Do you have this drug?’ For God’s sake, you are the ICU – that is where people should be coming to get this kind of drug! But you find out that they have to write a list of what patients have to go and buy outside the hospital.” Ironically, the ICU is the “intensive care unit,” whose name alone should suggest the most capable, well-equipped unit in a hospital.

A Culture of Cover-Up

A common contributing factor to incidences of medical negligence is greed. According to Dr. Ogungbo, doctors will sometimes take on cases outside of their areas of specialization – cases they are not qualified to handle, cases they cannot handle. He notes that this happens more often in private hospitals, where many doctors believe that they can do everything. “A gynecologist doing orthopedics, an orthopedist who says, ‘I’ve seen a doctor deliver babies before, don’t worry’ (I want the money, I will deliver the baby). In fact, there is a new [private] hospital just built and you have a list of all the specialties in the world. Well, you are trained in one thing, why not just do what you are trained in?” he asks.

Then there is the challenge of transparency with regard to deaths in many Nigerian hospitals. After a death occurs, there is hardly an investigation into the cause of death, nor are procedures created to prevent such deaths in the future. Dr. Ogungbo speaks of an experience at a hospital in Bangkok: “They have on their notice board something called ‘medication errors.’ All the staff, especially the nursing staff, are sensitized that they are monitoring errors: injection errors, whatever errors that had been made. So each month, they are looking to see what has happened wherever.” This type of monitoring has become standard practice in hospitals worldwide.

But Dr. Ogungbo says that such transparency is not the case in Nigeria. “Our own problem is that it is not open; there is a lot of cover-up. Even though we do what we call ‘morbidity and mortality’ every month, stating the number of people who died and why they died, nobody actually says, ‘This must never happen again and these are the things that we will need to put in place.’ Deaths are happening. We talk about it. But it is just that no one is saying, ‘Listen, we want sanctions.’”

The Patient’s Role

Medical negligence is not always the fault of medical personnel, however. There are times when negligence originates with the patient, through the lack of full disclosure to doctors, ignorance about medical conditions or even a lack of interest in treatment. Dr. Ogungbo gives an example: “You find a diabetic patient under treatment who continues to take soft drinks. Or a patient whose injury was being treated who was going around the ward with a glass of vodka – the glass was transparent. Of course, his condition did not improve.”

Dr. Ogungbo says these are some of the ways that patients can contribute to negligence during medical treatment. He emphasizes the importance of full disclosure of information to the doctor. “If you don’t give us the pieces of the puzzle, we can’t piece it together to see the picture. Patients – especially patients infected with HIV – leave out the fact of their diagnosis, but that is a critical piece of information. If they don’t tell us that, we are scratching in the dark, scratching our heads. It delays things, but once you say this, there are a lot more things that we can do. However, patients withhold that kind of information and it doesn’t help.”

Osanyin echoes the sentiment that it is important for patients to come clean about their medical history with their doctors: “Patients contribute sometimes by withholding information or confusing issues. Don’t forget, most of them may come when things are a bit too late because they have been to the herbalist, to the chemist and the pastor. And they’ve treated malaria. And the last resort is the hospital.”

RELATED: The New Nigerian Health Bill And What It Means To You

Perhaps if Nigerian patients become more proactive in their health and medical treatment, if medical personnel take more responsibility for the cases that they handle, and if the government begins taking health more seriously by building more hospitals and better equipping the existing ones, then we may finally begin to see a decline in cases of medical negligence. But until then, we are left waiting and wondering why, as medical negligence cases in the average Nigerian hospital continue to escalate, so few cases are reported, and even fewer prosecuted.

But that is a story for another day.

Has your life or the life of a loved one been affected by medical negligence? Share your story or thoughts on this issue below.