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For instance, a girl kept receiving the identical ineffective drugs for lots of days. For one other woman, it appeared that the frontline hospital didn’t have an agreed protocol for managing pulmonary oedema and pulmonary embolism. In one other case, the protocols for inverted uterus, heavy bleeding and extreme anaemia and hypovolemia have been either not obtainable or not applied. The root-cause evaluation was conducted on 30 deaths which occurred at the peak referral hospital in 2017 out of the total of 70 deaths in that location.

We are a full-service health department that performs many enhanced …