Case 27 Negative test results
A 23-year-old South African woman, Della, presents in active labour to a hospital in Wales at 3 am on Saturday morning. This is her second pregnancy and she has gone into spontaneous labour at 34 weeks gestation. She has antenatal notes with her from a hospital in London, which indicate that although she has no significant medical history or obstetric risk factors, she booked late (at 27 weeks) and she has not attended regularly for antenatal care since then. She came to the UK early in this pregnancy and has been staying with different friends around the country. Della delivers a healthy looking female infant, Rose, weighing 2.7 kg, within 20 minutes of arrival. The neonatal ST2 doctor on-call who was at the delivery did not need to resuscitate the infant. However he is concerned that he cannot find a HIV test result in Della’s notes. Della reports that she did have the test done, and that she had been told that all her blood tests were fine.
What would you do?
Based on Della’s statement the ST2 doctor documents the discussion in her antenatal notes, requesting the obstetric team to follow up Della’s HIV serology in the morning. He also adds a note at the bottom of the electronic handover sheet on the computer in the neonatal unit for the doctor on duty the next day to follow-up the result. Unfortunately, the handover sheet on the computer is not saved after the addition of baby Rose’s details and is lost when the computer ‘crashes’ later in the night. The ST2 has a busy night with 26 weeks gestation twins, and is exhausted by the morning. The patient handover the next morning is fragmented because the consultant, registrar and incoming ST2 doctor all arrive at different times. The ST2 doctor on night duty forgets to verbally handover the case to his colleague on duty for the day, and leaves to commence a 7-day holiday. Baby Rose remains well over the next 2 days and breastfeeds well, but is kept on the postnatal ward for observation due to her prematurity. On Monday morning the ST3 doctor covering the postnatal ward checks Rose’s notes and discovers that there is no HIV test result, and that the midwives on duty are not aware of any result or additional test having been obtained over the weekend. The ST3 doctor immediately informs her consultant.
What should be done now?
The consultant speaks to Della, counsels her and suggests that a rapid HIV test be performed. The result is positive, and the case is immediately discussed with the regional paediatric HIV specialist, who recommends starting baby Rose on combination therapy as post-exposure prophylaxis. Unfortunately, Rose is subsequently found to be HIV infected. Della is depressed, rather than angry, and does not make a complaint because she regards the issue as her fault. However, at the age of 18, her daughter Rose is extremely angry about having HIV and the impact it has on her life, and discovers that she can sue the hospital herself.
Expert opinion
With optimal management the risk of mother to child transmission of HIV should be extremely low, approximately 0.1%. This relies on identification of HIV infected women early in pregnancy, and rigorous implementation of guidelines for their management. A major reason why vertical transmission of HIV continues in the UK is the failure to identify all pregnant women infected with HIV. The Royal College of Obstetricians and Gynaecologists, and the British HIV Association recommend HIV testing for all pregnant women at booking, with timely delivery of results. For all women presenting in labour with an unknown or uncertain HIV status (which would include those with no documented result) a rapid diagnostic test should be performed, which yields a result within 20 minutes. This potentially allows the administration of nevirapine and other anti-retrovirals to the mother, delivery by Caesarean section, and administration of combination anti-retroviral post-exposure prophylaxis to the newborn within 4 hours of birth, all of which will reduce the risk of vertical transmission. In this case, prematurity, vaginal delivery and breast feeding are all risk factors for mother to child transmission. Failure to perform a rapid diagnostic test for HIV at the time of presentation in labour, and the subsequent failure to verify the maternal HIV status, meant that baby Rose did not have the opportunity to commence anti-retroviral therapy during the optimum time period (within 4 hours) after delivery and that breast feeding was permitted. Although this is the most important error that contributed to the mother to child transmission of HIV in this case, failure to give an adequate handover to the day-time neonatal team and failure to communicate directly and appropriately with the obstetric team probably compounded the problem by limiting the opportunity for other staff to spot the original error.
Legal comment
Rose will have three years from her 18th birthday to launch the claim before it becomes statute barred. She will first have to get disclosure of her own and her mother’s records and then take an expert opinion. That opinion must be based on the standards in place at the time of the incident.
It seems unlikely that the London hospital will be blamed. The results were probably not communicated to the mother, because she was lost to follow-up as she moved around the country visiting friends. The spotlight will therefore be on the hospital in Wales.
The Welsh hospital will probably wish to locate the ST2 doctor to see what he can remember. Although he recorded the need for a HIV test result in the notes, he appears to have then failed to address the matter with the required urgency. He will almost certainly no longer be able to recall the circumstances which prevented him from making an adequate handover.
The hospital’s lawyers will also consider whether Rose would have contracted HIV in any event. However, the Expert Opinion states that the failure to commence anti-retroviral therapy within 4 hours of birth and allowing the baby to breast feed were the most important errors that led to the child developing HIV. It seems likely that on balance, Rose would not have acquired HIV, if appropriate treatment had been given. If this is what the instructed experts conclude, then the case will have to be settled.
The hospital’s lawyers will, however, argue that some or all of the fault should be placed with Della, the mother, who appears to have given an inaccurate history. They will want to investigate if her negligence contributed to the outcome. This is a matter for negotiation between the lawyers. If the matter cannot be resolved by negotiation, then the judge will have to provide a percentage figure for the reduction in the damages, based on the culpability, if any, of the mother.
