20/11/2025
RE: REPORT ON CASE OF ALLEGED MEDICAL NEGLIGENCE AT COTTAGE HOSPITAL, ADEWOLE
Case Reviewed: Mrs. A M (Booked Primigravida)
Facility: Cottage Hospital, Adewole
Date of Incident: 16th–17th November 2025
Audit Date: 20th November, 2025
1. Background:-
This report presents the findings of a clinical and administrative audit conducted on the intrapartum care and perinatal outcome of Mrs A M, a booked primigravida who received antenatal care (ANC) at Cottage Hospital, Adewole and subsequently experienced a perinatal death on 17th November 2025.
The audit was conducted to ascertain clinical processes, adherence to protocols, documentation quality, communication flow, and overall institutional responsiveness in the management of the case.
2. Summary of Clinical Audit Antenatal Period:-
• Patient attended ANC regularly.
• Pregnancy remained uneventful until 40 weeks’ gestation.
• At 40 weeks, BP recorded as 146/108 mmHg with no proteinuria.
• Patient was commenced on Tablet Aldomet (Methyldopa).
Presentation in Labour – 16th November 2025:-
• Patient first presented in the morning with 2 cm cervical dilatation, presence of show, and diagnosis of passive/latent phase of labour.
• She was counselled to either stay or return home and advised to come back when contractions intensified.
Second Presentation – 7:05 PM:-
- Returned with intense labour pains.
- Examination revealed:
- 6 cm cervical dilatation
- Meconium-stained liquor
- Diagnosis: Fetal distress.
- Labour was augmented with 5 IU oxytocin
Progress of Labour:-
• 9:00 PM: Cervical dilatation 8 cm.
• 10:00 PM: Fully dilated with urge to bear down.
• Delivery: Episiotomy performed; baby born with poor APGAR score.
Newborn Resuscitation:-
• Resuscitation carried out using:
o Suctioning
o Tactile stimulation
o Radiant warmer
o Oxygen administration via oxygen concentrator
• Despite efforts, resuscitation was unsuccessful and perinatal death was declared.
• Father was promptly informed.
Maternal Post-Delivery Care:-
• Mother received:
o 10 IU oxytocin
o 600 µg misoprostol (PPH prophylaxis)
• Episiotomy repaired; however, perineal amd cervical tears repairs were challenging.
Referral:-
• Patient was eventually referred at 12:05 AM on 17th November 2025.
Clinical Recommendations:
1. Immediate review by a doctor for:
o meconium-stained liquor
o hypertensive patient in labour
o poor labour progress
o fetal distress
2. Reinforcement of oxytocin administration protocols.
3. Mandatory presence of a skilled team for newborn resuscitation.
4. Immediate referral for fetal distress when operative delivery is not available.
5. Continuous training of health workers in professionalism, patient care, empathy and customer service.
Conclusion:-
As a responsible agency of government, we wish to first express our deep and sincere sympathy to the mother, the father, and the entire family at this difficult time. No family deserves such pain, and we share in their grief.
Every life is precious to us, and whenever an adverse outcome occurs, it touches not only the family but also the entire health system. Our commitment as a government agency is always to safeguard all patients including mothers and babies, and we take this responsibility seriously.
Cottage Hospital Adewole delivers an average of 2 to 4 babies' every night making an average of 75 to 120 successive deliveries per month. As of November 2025, they have successively delivered 990 babies and recorded 4 neonatal deaths, the incident been addressed brings it to a total of 5.
In line with our mandate for accountability and quality of care, the Hospital Management Board constantly monitors and supervises all state-owned hospitals, but we also recognize the significant workload pressures faced by our frontline health facilities, including Cottage Hospital Adewole. Despite these challenges, our health workers continue to give their best every day under demanding circumstances.
Nonetheless, the Board remains committed to addressing system gaps and improving working conditions so that all patients including mothers and babies continue to receive the safest possible care.
We assure the family and the public that we care, we are listening, and we will always act responsibly based on verified findings. Our focus remains on strengthening maternal and newborn services and ensuring that every family in Kwara State can trust the care they receive.
Signed
Management
Kwara State Hospitals Management Board