Kidney donor death: 'She couldn't have been saved'

Kidney donor death: 'She couldn't have been saved'

Blood loss 'too ferocious', says defence witness.

Sat, Feb 28, 2009
The New Paper

By Ng Wan Ching

NO amount of monitoring would have saved her.

What happened to Madam Narindar Kaur (top, with a shot of some renal clips) was so sudden and so catastrophic that she would have died anyway.

That was the view of two doctors who gave evidence in court yesterday in the medical negligence suit that Madam Kaur's husband has brought against her two surgeons and the National University Hospital (NUH).

Dr Howard Lau, a renal transplant expert from Sydney, Australia, was the witness for Dr Li Man Kay and Dr David Consigliere, the two surgeons who operated on Madam Kaur, as well as NUH.

Madam Kaur donated her kidney to her husband, Mr Surender Singh, in February 2005. She bled to death hours after her operation from an open renal artery.

Dr Lau said that in Madam Kaur's case, the blood loss was 'so catastrophic, it was so ferocious', that he did not think any amount of monitoring would have made a difference.

That was because the window of opportunity to administer effective treatment was not enough, with the amount of bleeding and the degree of rapid deterioration.

'I do not think rapid and frequent evaluation was going to make any difference. We had an exceedingly rare complication here, and that is why it is being looked at carefully,' he said.

Madam Kaur's family is asserting that her vital signs were not monitored adequately. If they had been, she might have been saved.

She was supposed to have received hourly monitoring of her blood pressure, heart rate and pulse rate - among other measurements - after she was transferred to the general ward on 16 Feb 2005.

But from 2.30pm to 4pm, there were no records of any monitoring.

Mr Singh's lawyer, Mr S Palaniappan, asked whether the blood loss could have been more gradual, whether it was possible that a hem-o-lock clip that had been hanging on halfway, could have fallen off subsequently.

Dr Lau said it was possible but not likely, the reason being that once the pressure had been relieved, there would not be the same intensity of pressure to push the clip off.

Dr Lau pointed out that it was very important to say that there are not many people who have seen a renal artery bleed.

Ferocious bleeding

'I have. Renal artery bleeding is ferocious, that is why it is written everywhere this is a major concern, even though it is such a rare occurrence,' he said.

The other witness was Associate Professor Lim Boon Leng, head and senior consultant at the department of anaesthesia and surgical care at Singapore General Hospital.

He was asked by Mr Palaniappan whether it would have been possible to have had better results with resuscitation if Madam Kaur's condition had been picked up earlier.

Assoc Prof Lim said that this was only possible in a partial slippage scenario. And that is only possible with the smaller arteries.

'The so-called partial slippage of the clip, (is) only possible in smaller arteries or in the veins where the pressure is much lower,' said Assoc Prof Lim.

His opinion is the clip on this kind of big artery with high pressure is either on or completely off.

Mr Palaniappan asked whether the outcome would have been better if resuscitation attempts had been done at some point in time in the operating theatre, where there would have been a better possibility of Madam Kaur being operated on and the blood loss being stopped.

Assoc Prof Lim said that with the renal artery being open, there is no way one can replace blood or fluid fast enough to maintain reasonable good blood pressure to go to operating theatre.

The hearing ended yesterday. Lawyers will now prepare their submissions to the judge.

ABOUT THE CASE

Madam Narindar Kaur died on Feb 16, 2005, after a three-hour operation during which her left kidney was removed to be transplanted into her husband, Mr Surender Singh.

The surgery was uneventful, but hours later, she became breathless and pale. An emergency team spent about an hour trying to resuscitate her.

Her death is believed to be the first donor fatality in almost 30 years of living-donor kidney transplants here.

An autopsy found she died from sudden internal bleeding in her abdomen. The clips used to stop blood flow on the cut end of her renal artery had apparently slipped.

PLAINTIFF'S WITNESSES

1. Ms Jasmail Kaur, Mr Singh's sister

She said she saw Madam Kaur in the general ward looking 'very pale and cold, and very, very breathless' when she visited her on 16 Feb 2005. She raised the alarm.

2. Associate Professor Gilbert Lau, forensic pathologist

He said Madam Kaur died from intra-abdominal haemorrhage attributable to the apparent slippage of the clips applied to the cut end of the left renal artery.

3. Professor Michael Nicholson, British transplant surgeon

He said the operating surgeons' testimonies did not gel with the autopsy findings.

But he felt it was unlikely that the pathologist had made a mistake about the size of the clips.

THE DEFENDANTS

1. Dr Li Man Kay

2. Dr David Consigliere

3. National University Hospital

Dr Li and Dr Consigliere dispute the forensic pathologist's findings. Assoc Prof Lau said he found four clips which had apparently slipped off the renal artery, leaving it open. Dr Li and Dr Consigliere both say they had used only two clips to close the renal artery. They also dispute her cause of death.

DEFENDANTS' WITNESSES

1. Professor Christopher Cheng, head of Singapore General Hospital's urology department

He said the clips could have been dislodged during the act of evisceration (removal of the abdomen's contents).

He found it highly unlikely that four clips had been applied on the donor renal artery.

2. Dr Howard Lau, renal transplant expert from Sydney Australia

3. Associate Professor Lim Boon Leng, head and senior consultant, anaesthesia and surgical care department at Singapore General Hospital

Both said that the bleeding that Madam Kaur suffered was so fast and furious that she could not have been saved.

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This story was first published in The New Paper.

http://health.asiaone.com/print/Health/News/Story/A1Story20090228-125136.html