Tragic case: When a failure to communicate leads to the death of an unborn child

In a tragic case of “communication breakdown” that ended with the death of an unborn child and subsequent sanctions against two nurses, an Alberta doctor has been found guilty of failing to provide the minimum standard of care to the patient and her baby. Dr. Jacquie McCubbin, an obstetrician-gynecologist in Edmonton, has been ordered by the College of Physicians and Surgeons of Alberta to pay up to $15,000 in hearing costs and to complete two patient safety courses. “Dr. McCubbin’s proven unprofessional conduct was not the result of any malicious or abusive behaviors towards her patient or actions that defrauded the healthcare system,” wrote the hearing tribunal in its decision document. “Instead, her proven conduct was a result of her trusting inaccurate misinformation she obtained from other team members she was relying on during a busy on call shift.” After a complicated pregnancy that required several hospital stays and the administration of Cerdivil—a vaginal insert that helps relax and dilate the cervix—the patient went into labour in December 2017 on a busy night in the labour and delivery unit. Read: Failure to communicate: Doctor hit with $20,000 penalty for breakdown in pre-op anticoagulation bridging plan According to the decision document, a number of actions or inactions ensued that contributed to the baby’s death, including: the attribution of an abnormal fetal tracing entirely to the effect of medications given to the mother, interruption of fetal heart monitoring at crucial points during labour, lack of fetal monitoring after the mother was transferred to the labour and delivery unit and after abnormal fetal tracing had already been reported, and the administration of oxytocin when the fetal heart rate tracing had registered as abnormal. “Concerns were also raised about Dr. McCubbin’s lack of communication with the parent and her partner about the possible implications of a non-reassuring tracing and what that might mean for delivery options,” wrote the discipline tribunal. “Such communications should have also been documented.” With several C-sections scheduled for that night, Dr. McCubbin was personally assessing patients only if the nurses asked her to for a specific reason, according to the decision document. However, while Dr. McCubbin was relying on the nurses on duty to provide her with accurate information so she could act accordingly, the hearing tribunal noted that this does not mean the nurses should bear all the responsibility and fault. “The hearing tribunal understood from the evidence that the parent’s pregnancy was complicated, and she required several hospitalizations to manage pregnancy-related issues leading up to her delivery,” wrote the tribunal. “Given this and the presence of some signs on the fetal tracing that suggested the delivery may not have been evolving smoothly and safely, the Hearing Tribunal found the ultimate responsibility would have been on Dr. McCubbin to ensure the safety and well-being of the parent and her unborn child.” Dr. McCubbin has since made changes in her personal practice as a result of this case, according to the decision document. The hospital where she works has also implemented process changes within the labour and delivery unit to improve communications amongst care team members. Read: Ob-gyn arrested and charged with two counts of sexual assault

Tragic case: When a failure to communicate leads to the death of an unborn child

Register for free access or login.

Related Topics