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A 21 year old Sri Lankan woman had given birth to her first baby on 16 July. At that time, she spoke very few words of English; the antenatal records revealed at 16 weeks that she spoke Tamil, and an interpreter was required. As the clinics progressed at two monthly intervals, it was repeatedly noticed that she needed an interpreter.
After delivery, the mother wished to breastfeed, starting in the postnatal ward on the day after birth. She believed her baby was feeding well, although the following day he started to cry, apparently inconsolably despite repeated breastfeeds. His mother worried he was hungry, and twice called the ward staff. The mother described how on one occasion, the midwife placed the child supine and tried to pacify him, failed to do so, then returned the baby to her and departed. The mother persevered with feeding, and whenever a nurse passed by they would smile and nod at each other, but no words could be exchanged, and the mother could not communicate her increasing concerns for her crying infant.
The mother was adamant in her evidence that at no stage during her admission did the midwives explain how to breastfeed her baby, although she was taught how to change a nappy.
On Sunday, 18 July, her husband (who spoke basic English) was asked in the evening to take his wife and baby home; the mother told the court she did not understand that she was being discharged, but remained concerned about her baby’s constant crying. She asked her husband to relay to the midwives her anxieties, and to explain she had received no assistance throughout the day in resolving the infant’s distress. Whilst placing the baby in the car seat, a midwife explained it was normal for newborns to cry, and this advice was repeated to family members on several occasions.
The baby went home with his parents, and he continued to cry through the night, irrespective of his mother’s efforts to breastfeed. By morning, he made less effort to feed; she reasoned he had tired himself crying. A midwife who visited him at home discovered the baby to be pale and lethargic. On admission to hospital he was hypoglycaemic, and as a result had suffered catastrophic brain injury, resulting in severely impaired physical and cognitive function. The court found, after litigation, that this was a result of the child not being fed; 12 to 15 hours of non-feeding were sufficient to exhaust energy reserves and result in profound hypoglycaemia, followed by irreversible cerebral injury.
The court found that the devastatingly simple cause was attributable to the baby’s mother having no knowledge of how to breast feed, and crucially, no knowledge of what to do if there was poor feeding.
The court also found that the mother’s (albeit timid) attempts to engage with the midwives had been ignored. The discharge process had been conducted without interpretation facilities for the mother, and failed to give the concerns that were being raised about the baby the attention and consideration that they deserved. By repeating to the father a mantra that ‘it is perfectly normal for a newborn to cry’, false reassurance was given to the family, discouraging them from repeating once more the concerns already raised, ostensibly allayed.
Treating every year more patients who require language interpretation, we must be alert to the grave risks that flow from failure to communicate with our patient. No clinician can assume that apparently intuitive, instinctive acts such as feeding a baby are necessarily adequately understood by the patient. Providing elementary information may be straightforward when we share a common language with the patient. But when needs be, please ensure successful interpreted communication before discharge.
Department of clinical law, June 2018