By Udie Soko
In 2019, the World Health Organization (WHO) established World Patient Safety Day to be observed annually on 17 September by the global community. Each year, a new theme highlights a priority area where action is needed to reduce avoidable medical harm. This year’s theme is “Engaging patients for patient safety”, with the slogan “Elevate the voice of patients.”
Udie Soko at the WHO Global Conference
Photography by Tsalachworth Consultancy Limited
In 2013, I was invited by the WHO to become a Patients for Patient Safety champion. This opportunity was of great importance to me, given that I had suffered medical harm in 1989 due to being misdiagnosed with tuberculosis (TB) of the lymph nodes and consequently put on anti-TB injections.
Photography by Tsalachworth Consultancy Limited
The lab report later revealed that I had cancer of the lymph nodes and no trace of TB. I was only 23 years old then and did not have the wherewithal to pursue this misdiagnosis because I had an enormous dragon to slay - called cancer.
This blog is not about cancer but, more specifically, a cancer of neglect, patient harm, and premature deaths. It is based on my speech at the World Patient Safety Day Global Conference held in Geneva, Switzerland, on the 12th and 13th of September, 2023. Approximately 120 participants attended the Conference, and over 800 joined online worldwide.
Udie Soko at the WHO Global Conference
Photography by Tsalachworth Consultancy Limited
In 2021, I volunteered to sit on the World Patient Safety Day Steering Committee. After a bit of back and forth, it was agreed that the theme for that year would be “safe maternal and newborn care”. I thought it somewhat ironic since I do not have biological children and felt pangs of the imposter syndrome sneak in occasionally. Little did I know that the theme would soon directly impact my life, changing it forever.
One of my greatest pleasures is taking long, leisurely walks, especially on weekends. During one such walk, while contemplating my workload, my phone rang abruptly, interrupting my thoughts. Reluctantly, I answered it, and my nephew Kelvin, the son of my late brother, was on the other end of the line. He spoke briefly about wanting to grow maize on my brother’s farm and sought my blessings. I told him I would first ask my elder brother for his opinion.
A few hours later, my nephew called me back. Impatiently, I answered the phone, assuming it was still about the maize issue. However, it turned out to be something else entirely. He called to inform me that his sister Violet, or Vi for short, had been rushed to one of our major government hospitals because she was experiencing excruciating pain. Her local clinic had done all it could to assist, resorting to referring her to a better-equipped facility. Taken aback, I asked him to keep me updated as he and his wife were heading to the hospital.
Several hours later, I called him for an update. It was then that I learned that my niece was six months pregnant. The doctor decided they would perform a Caesarean section (C-section) if she failed to deliver the baby naturally. My nephew said the doctor had also advised him and his wife to go home and return in the morning.
I could not sleep the whole night, waiting anxiously for the sun to rise. Just before 6 A.M., Kelvin called. How is Violet? I asked with a quiver in my voice. Vi and the baby have both died; he said matter of factly: silence and more silence. As we planned for her funeral, the following days felt like a blur: so many questions, yet too few answers. Although gone, they will forever live in our hearts.
After we put her to rest, I inquired about what had happened. Her cousin, another niece and confidant, explained that Vi was reluctant to keep the baby when she fell pregnant as she already had three children. Eventually, she came to terms with it but wanted to keep it a secret for as long as possible. I also learned that she used to go to a private clinic for her pre-natal checkups instead of her usual government health centre because she was not happy with the level of care. After all, several of her friends had taken this private route and had delivered successfully. I was told that at her last check-up a few days before her death, the doctor at the private clinic said she could not hear the baby’s heartbeat. On the other hand, Vi insisted that she could feel the baby moving occasionally.
Vi began experiencing premature contractions on that fateful day and grudgingly went to the local clinic. Noting the dire situation, the health personnel arranged for their ambulance to rush her to the hospital without her medical records. This was surprising because she had been attending that clinic for over ten years. Consequently, the doctors at the hospital, who did not have any medical history to refer to, began treating her based on assumptions. Finally, when things worsened, they took her to the theatre to perform an emergency C-section).
Violet and her baby girl died on the operating table. The official cause, according to her death certificate, is a major obstetric haemorrhage. For the family, it translates to she bled to death. Without knowing for sure the facts leading up to her demise and her actual passing away, we believe the following things could have been done by all parties to possibly prevent her death.
The private clinic could have proactively encouraged Vi to seek a second opinion, which could have been facilitated by contacting her husband or other family members, mindful of patient confidentiality.
It could benefit future patients like Vi if medical records were made available in a digital format, as this would offer a more convenient and efficient way of accessing and sharing important health information.
The government hospital maybe should have operated on her much earlier rather than four painful hours later.
After much soul-searching, our family has committed to increasing communication and spending more time together. In addition, we have decided to support each other in seeking prompt medical attention and be present for each other, no matter the outcome. Furthermore, we chose to use our experience to promote patient safety further. This we strive to do through the Zambian Cancer Society, an organisation I founded in 2009 to support cancer patients and their caregivers irrespective of age, gender or type of cancer.
Despite our loss, according to an article by Lusaka Times dated 8th March 2022, “Zambia has made significant strides in the past two decades to improve maternal and newborn health outcomes. The maternal mortality rate dropped nearly 300 per cent in 16 years – from 729 deaths for every 100,000 live births in 2002 to 278 deaths per 100,000 in 2018.” While this gives us cause to Hope, we know that a lot still needs to be done to bring down these numbers even more.
Vi died in the prime of her life at 31, leaving behind three children now aged 14, 10 and 4. Losing a loved one is never easy, but through our Christian faith, we are comforted that we shall meet again one day. Vi has passed on, but she will forever live in our hearts.
Udie is a big dreamer and risk-taker who uses her creativity to support cancer patients and their caregivers through the Zambian Cancer Society.
Connect with her on Facebook: Udie Soko
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Edited by Bwalya Mphuka
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