SINGAPORE - She was only three years old, and she was undergoing her second liver
transplant.
Unfortunately, she developed
complications after her transplant and died.
Wednesday was the coroner's
inquiry into the death of Nadia Abdullah, who was born with a liver condition.
The coroner's court heard that
Nadia had a history of biliary atresia - a congenital lack of bile ducts to
drain bile from the liver.
She also had a medical history of
beta-thalassaemia trait and iron-deficiency anaemia.
Nadia, who was born on Feb 7,
2006, underwent an operation about a month later to allow the drainage of bile
from her liver, but it was not successful.
Her liver functions then began to
fail. About two years later on April 10, 2008, her mother, Ms Norhayati Amir,
donated part of her liver to her.
The liver transplant was carried
out at the National University Hospital (NUH).
But various complications occurred
- anaemia was noted about 18 months after the transplant, among others.
Soon, she needed a second
transplant. She was put on the waiting list for a cadaver liver - liver donated
by a donor who is brain-dead.
Within months, a suitable and
matching liver was found on the evening of Jan 13, 2010. The donor was a
30-year-old healthy woman, who suffered a stroke of the brain.
Nadia was admitted into NUH again
the next day, for a scheduled second liver transplant.
Did spat with doctor lead to toddler's death?
Professor K Prabhakaran, the head
of department of Paediatric Surgery of NUH, performed the operation.
Dr Dale Lincoln Loh Ser Kheng, a
senior consultant in the Department of Paediatric Surgery at NUH, assisted him
together with other surgeons.
The operation went well, but
Nadia's cardiovascular status became unstable.
She later became unresponsive and
remained in the paediatric intensive care unit (ICU) of NUH until her death on
Jan 29, 2010 - about 15 days after the second transplant.
But Ms Norhayati, 28, who is a
nurse, was concerned over the cause of death of her daughter. She raised
several issues.
She was concerned over whether Dr
Loh had performed the second transplant properly because she had a spat with
him in the morning of the operation.
This was over the issue of
consent - Dr Loh had obtained the consent for the second liver transplant from
Nadia's grandmother instead of her, as Ms Norhayati wasn't in NUH at that time.
When Ms Norhayati was asked to go
to NUH urgently the next morning to give her consent, a quarrel ensued.
Quarrel
The quarrel was between her and
Dr Loh over the urgency of the issue and why she was not asked for her consent
the evening before.
Dr Loh confirmed that "he
did not do anything knowingly" which would cause Nadia's death.
Also noted was his role as one of
the assisting surgeons and not as the main surgeon.
Ms Norhayati was concerned over
whether NUH had done any proper checks to ensure that the donor's liver was a
suitablematch to Nadia.
Dr Loh confirmed that the liver
was an appropriate and suitable match - the donor had the same blood type and
was below 40 years old, among others.
An independent expert, Associate
Professor Loh Tsee Foong, the head and senior consultant from the Children's
ICU of KK Women's and Children's Hospital, added that the complications Nadia
had suffered were not unexpected in liver transplant.
Apart from the frequency of
monitoring of ammonia level, the overall care and management given to Nadia was
reasonable, he said.
Ms Norhayati said she would not
have agreed to the second transplant if she had been informed that the donor
was lupus positive.
But an independent expert, Dr
Ravishankar K Diddapur, consultant surgeon from the Specialist Surgery,
clarified that a donor who is lupus positive is not known to affect a recipient
and screening for lupus antibody is not recommended as the risk is considered
small.
NUH also clarified in a report
that the screening for lupus positivity was not one of the routine blood
investigations in donor screening.
Ms Norhayati asked how Nadia had
caught the superbug MRSA.
As Nadia had multiple admissions
into the hospital, Dr Ravishankar said it was difficult to ascertain when and
how she had got the infection.
Ms Norhayati asked if the
cardiopulmonary resuscitation (CPR) done on Nadia could have caused bleeding in
her brain and if the bleeding could have been managed medically.
Prof Loh said in his report dated
May 7 this year that it is possible that CPR may result in intracranial
bleeding, but it would be an unintended side effect.
He also stated that the bleeding
area in the brain was small and did not appear to cause a significant pressure
on the brain and neurosurgical intervention is more likely to be harmful than
of benefit to Nadia.
Police do not suspect foul play
in Nadia's death.
Before State Coroner Imran Abdul
Hamid presented his findings, he offered his condolences to Ms Norhayati.
He then addressed her concern
over the spat.
He said: "Despite the spat,
it has not affected the transplant itself. The transplantation of the liver was
done without any technical issue and did not bear cause of death."
But he also noted that it would
be beneficial if Dr Loh had spoken to Ms Norhayati directly instead of to
Nadia's grandmother.
He also noted that "a single
parent's responsibility can be tremendous".
When the liver fails
Nadia died from multi-organ
failure as the liver graft had failed to thrive and complications arose. The
unstoppable events had then led to Nadia's death, he said.
Liver failure happens when large
parts of the organ become damaged beyond repair and it is no longer able to
function.
It is life-threatening and
demands urgent medical care.
Most often, liver failure occurs
gradually over many years.
But a rare condition known as
acute liver failure occurs in as little as 48 hours and can be hard to detect initially.
The most common causes of chronic
liver failure include hepatitis (B and C), cirrhosis (irreversible scarring of
the liver), hemochromatosis (an inherited disorder that causes the body to
absorb and store too much iron) and long-term alcohol consumption.
In children, it is caused by
biliary atresia, a condition which begins soon after birth, where the bile
ducts fail to develop normally and are unable to drain bile from the liver.
Early symptoms of liver failure
include nausea, loss of appetite, fatigue and diarrhoea. These can develop into
jaundice, mental disorientation or confusion and even coma "should the
condition worsen".
For liver failure resulting from
long-term deterioration, the initial treatment is to save whatever part of the
liver that is still functioning.
Waiting list
If this is not possible, then a
liver transplant is required.
As of March, more than 500
patients with organ failure are still waiting for donor organs.
Of these, 448 are on the National
Kidney Transplant waiting list while on dialysis, while 28 are in the queue for
new livers, six for hearts and 22 for corneas.
Chai Hung Yin
The New Paper
