Tempering with Patient’s Case Note at University Of Abuja Teaching Hospital, Gwagwalada.
At the University of Abuja Teaching Hospital, the management of the hospital led by the Chief Medical Director (CMD), Dr. Peter Alabi expunged materials; altered notes and inserted write-up in a case note of Mr. Popoola Gboyega to deliberately misled investigations into the cause of his death. The case note number of the patient is 193442.
Mr. Gboyega Popoola was a 65year old man who presented with low back pain of long duration radiating to the lower limb. He had difficulty walking for a short distance without rest and he noticed a gradual decrease in his walking distance. He had difficulty with his urination, defecation and sustaining erection. He was a known hypertensive and diabetic who had been attending regularly clinic in our hospital with good control. He was investigated after a thorough physical examination and his Magnetic Resonance Imaging (MRI) scan showed multiple disc disease and canal stenosis at lumbar spine (L3-S1). A diagnosis of lumbar spine degenerative disease was made with segmental instability. He was planned for surgery and properly counseled which he accepted.
In view of his co-morbid conditions, a thorough assessment of his cardiac function was done by the cardiologist who certified him fit for surgery. He was also reviewed by the endocrinologist and cleared for surgery. Finally the anaesthetist reviewed him and was cleared to have his surgery. The surgical plan was to decompress his spinal canal from L3-S1 and surgically stabilized with pedicle screws and rod following a postero-lateral fusion with autogenous bone graft.
On the day of the surgery 10th May 2011, the theatre manager Mr. Samsel refused to allow the surgery without any reasonable excuse. He claimed that he will not allow any instrumentation from outside to be brought into the theatre to operate on a patient. The hospital does not possess a spine surgery instrumentation set yet he did not want the surgeon to operate with the one available. Mr. Samsel antagonism was due to my reporting him to the CMD that he has been stealing from the hospital through over-invoicing, quoting similar equipment and implant with different name and using proxy to supply equipment and implant to the hospital without tender.
This event of cancellation of surgery was reported to the CMD, Dr Peter Alabi who said I should go to beg him to allow me to do the surgery. The Chairman, Medical Advisory Committee, Dr Ted Agida intervene and beg Mr. Samsel to allow me use my instrument set. On the 13th May 2011, I entered the theatre at 7.30am for the surgery and waited till 10.30am when the peri-operative nurse in charge of the theatre entererd the theatre and claimed he was not aware of the case inspite of the operation list. I saw the instrument set I have brought in for sterilization on the table “unsterile”!
I left the theatre and went to the CMD, Dr Peter Alabi who called Mr Samsel to brief him what has happened. He claimed he was ready for the case that I was only crying wolf. I asked the CMD to send the Chairman Medical Advisory Committee to investigate. At the point all the CMD could do was to ask us to go to settle our difference. No reprimand; no query! This act further embolden the theatre manager; Mr Samsel.
Following the second cancellation, Mr. Gboyega Popoola asked his lawyer to write to the hospital and institute a legal action on the hospital. This jolted the hospital management to action and now begged me to undertake the surgery ASAP. I eventually did the surgery with successful post-operative outcome.
Post operatively, the power in the lower limb was grade 5and there was improvement in his bowel and bladder function. I discharged the patient to the endocrinologist after 72hrs for further follow up. The wound site was dry and clean and the patient was ambulant and reviewed by the physiotherapist who started his rehabilitation. Few days later, the blood pressure and the sugar level were high and the house-officer in Medicine took instruction from his consultant on the phone and an overdose of insulin was given and the patient became comatose.
The patient was rushed to the ICU and for 8hours, the endocrinologist nor the senior doctors I anaesthesia were sent for to review this patient! The patient was eventually resuscitated and was noticed to have suffered a stroke. This was the situation of the patient till he died in our facility.
It was not what we did that lead to the death of this patient that was terrible, it was what we did following his death that made me know that I work in an institution where the management headed by Dr. Peter Alabi will do anything to save their hide! It was also during this period that a pregnant woman fell of the operating table and eventually died and the management invented lies to cover up the case.
After the death of Mr. Popoola Gboyega, the lawyer descended on the hospital and in-order to save their faces they decided there must be a fall guy who has to be the surgeon that is in the bad book of the management for his outspokenness. At this juncture, I have accused the CMD for buying a refurbished C-Arm which cost N1.5million for N18.9million. The plot was hatched to ‘sex-up’ the case note of the patient, Mr Gboyega Popoola. As this was my own patient, I hurriedly photocopied the case note and kept it. There is a copy of this case note with the Independent Corrupt Practice Commission (ICPC) in a new case of mismanagement of another patient by the hospital management of University of Abuja Teaching Hospital, Gwagwalada.
What did they do to the case note? Parts of the notes were expunged and new one was written, insertions were done in the case note to change the flow of events and outright falsifications were also done. This is the most criminal aspect of the case!
The staff of the hospital involved in this case were taken to the hospital lawyers where they were coached to lie against me. This case fell apart when one of the staff refused to go on with the lie and informed me of the hospital plan to lie against me. This issue was resolved out of court and the management waddled on as if nothing has ever happened.
I have the photocopy of the case note of Mr. Gboyega Popoola which is also with the ICPC. I challenge the hospital to open the original case note of Mr. Gboyega Popoola to Nigerians so I can show the world how Dr. Peter Alabi supervised falsification of hospital record of a dead patient to exonerate himself.
Few years on, the management of the University of Abuja Teaching Hospital Gwagwalada is at the ICPC to answer to the question of how a patient was mismanage and event are showing that the same set of people have started to change what truly transpired, lied about their roles, intimidate junior staff to perjure just to ensure the surgeon is jailed or found culpable.
This time around the surgeon is ready and the eyes are on the goal. This is the field and this is the horseman! This is the time for change; change in the way we conduct our public affair which is a trust we would all account for.