Malacca Hospital deaths II: DAP calls for public inquiry into the mass infant deaths in November

Speech by Ketua Pembangkang dan DAP Member of Parliament for Kota Melaka, Lim Kit Siang, in the Dewan Rakyat on 9.12.1975 to cut the salary of the Health Minister by $10 during the 1976 Committee of Supply debate.

Malacca Hospital deaths II: DAP calls for public inquiry into the mass infant deaths in November.

I rise to move that the Minister of Health’s salary be cut by $10.

It was only less than two years ago on January 14 and 15,1974 that I had moved a similar motion to but the salary of the Minister of Health over the mass deaths in the Malacca Hospital caused by blood poisoning because of the breakdown of the hospital’s autoclave during the months of July and August 1973.

I do not enjoy mobbing motions to cut any Minister’s salary. In fact, I feel very and that even before the complete conclusion of the Malacca Hospital autoclave blood poisoning deaths, there should be another outbreak of gross negligence in the Malacca Hospital causing another spate of unnecessary deaths.

This time, the spate of deaths is confined to infants, who were born in the Malacca Hospital during the month of November.

Babies born fit and well would die a few days later, bleeding in the mouth, nostrils and rectum, and turning blue-back. According to my sources, there were more than 20 cases of infant deaths.

I will give some case histories:

1. Baby of Zalika binte Ahmad, of Kandang, Malacca, who is a government clerk. After pregnancy of 9 ½ months, admitted into the Malacca Hospital on 23.11.1975 and gave birth to a 6 lb. 12 oz. girl, who is her first child, on the morning of 24.11. The baby was placed in the nursery and died on the third day on 26.11. The parents saw a blue-black patch on her right leg.

Cause of death was given as “brain damage due to foetal anoxia” or lack of oxygen. Che Zalika went for regular pre-natal medical check-ups, on 14 separate occasions from June 5 to Nov.20. Her blood count and pressure was normal.

When the father asked the doctor why his baby died, he was told that the baby was weak in the womb. When the father asked why there was no indication from the regular check-ups his wife had received, the doctor said he knew nothing about this.

2. Baby of Zamalia binte Osman of Alai, Malcca. The mother was admitted into the Malacca Hospital on 13.11 at 2.30 a.m. A baby girl was born at 2p.m. and died at 2.30p.m. This is a case of premature birth as the mother was in the seventh month of pregnancy.

The father, a Malay teacher, is very bitter about the rudeness and indifference of the nursing staff. He complained that when he took his wife to the Hospital at 2.30, no doctor came to attend to his wife until eight hours later at 10s.m. despite his repeated pleas to the nurse on duty to fetch the doctor as his wife was in great agony and pain.

The Che Gu knows that he cannot bring back his first-born baby to life, but he wants to see a thorough reform and overhaul of the hospital administration to ensure that what his wife experienced would not be experienced by others.

Infant, Tan Hock Chuan, male of 16B Ayer Lelah, Malacca, first baby a salesman. The baby was born on 13.11.75 at 12.45 p.m., weighing 5 lb. 2 oz. Normal birth. The baby was out by the side of the mother in the maternity ward, which showed that the baby was in good health. The mother and baby were discharged on 15.11. The baby boy refused to take milk, kept crying, and was brought back to the Malacca Hospital on 19.11.75 by the grandmother.

Blood test was taken. As the baby kept crying and no attention was given by the hospital staff, the grandmother got permission to bring the baby home the same evening, on 26th Nov., the baby was re-admitted into the Malacca Hospital at 2 a.m. on the recommendation of a private practitioner, and died six hours later at 8 a.m.

The cause of death was given as “intestinal obstruction” n the death certificate, although the hospital authorities has put the cause of death as “severe dehydration due to gastro-entritis” of diarrhoea. I understand these are two very different causes of death, and I want to know why these two different causes of death are given in this one case.

4. Baby of Wong Fook Moy of KAMPONG Lapan, Malacca. Born on 16.11.75 at 9 pm and the baby weighed 7 l b. 4 oz. Baby put in nursery. Mother was discharged on 23.11.75, but baby remained behind at nursery. Asked by the mother about the condition of the baby, he doctor assured her and said the baby would be all right. When the parents visited the baby on 24.11, they found that the baby had been sent down to the Children’s Ward. The baby died on 26.11, The parents found out later that the baby had diarrhoea, which they were never told before.

5. Baby, Ong Koh Seng, male of Jalan Kilang , Malacca. Born on 23.11 at 8.30anm. The baby was taken home on 24.11 and on 25.11 the child became difficult and was referred to the Malacca Hospital for admission by a private practitioner on 26th, and died in the same day. Cause of the death given as “neo- natal jaudice and anaphylactic shock.”

6/ Lim Hong Koon , baby boy of a hawker at Bandar Hilir, Malacca. The mother was admitted on 21.11 at 9 a.m. , and gave birth to a boy at 3 p.m., the second children, by Caesarian operation. The first child a girl, was also born by Caesarian operation. The doctor advised the parents that a third birth would also be Caesarian and would be more dangerous, and advised that as they have both a girl and a boy, the mother should tie up the tubes to prevent future pregnancies, The parents agreed and the tubal ligation was done to prevent future pregnancies.

The baby was taken home on 23.11, while the mother was discharged on 30.11.75, the baby refused to take milk. Passed motion six or seven times a day, and on Dec, 4, at about 5 p.m., was admitted into the Hospital. At about 7 p.m., the mother saw the child’s mouth turning black, called the nurse who said it was the effect of the light. When pressed, doctor was called who ordered the baby to be given oxygen. The mother complained that it took some 20 minutes for the oxygen to be fixed up. The baby died at about 8.30p.m.

Apart from the distress of losing his second child, the father is also distresses because he had no son, and his wife had tied up the tubes to prevent the future pregnancies.

7. Baby of Sui Ah Lye, 34, house wife. Born on 15.11 at 7.30 a.m. weighing 7lb.12oz. This is the sixth children of a stevedore. The baby was taken to the nursery. The father saw the baby on 17.11 at about 11a.m. for the first time. On 18.11, the parents were told that the baby had died. The mother never saw the baby. No reasons were given to the parents for the death of the baby and no death certificate was issued.

8. Baby, Khoo Chee Chong, first born male of a wireman. This is a particularly tragic case, as this is the first child of a couple after 12 years of marriage, and which was by Caesarian operation.

The mother, Kwa Sian Kim, 33 was admitted on 12.11. The baby was born on the same day at 8 a.m., weighing 6 lb. 8 oz. The baby was put by the side of the mother in the maternity, which showed he was in a healthy state.

The baby was taken home on 15.11, while the mother stayed on until her discharge on 20.11. On 21.11, the baby was referred by a private practitioner for admission to the Malacca Hospital after the usual complaints of refusing to take milk, and yellowish in appearance. Put in drips. On 23.11, the baby was very pale and whitish, without colour of blood. The parents were told by a nurse that their baby had been cured of jaudice. On 24.11, the baby was put under oxygen and died on 25.11 with stomach bloated up.

On 15.11, before the baby was taken home, the baby was examined by the doctor who pronounced him fit and ‘ sihat’. When asked by the aggrieved mother the cause of death, the doctor told her that there was incompatibility of blood and promised that in her next birth, they would be more careful.

It would be noticed that out of the eight cases of histories I have cited, apart from the second case of a seventh-month premature birth, all the other cases involve normal babies.

Another striking feature is that all the babies who died were born in the period from 12.11 to 23.11. It is clear that an infection took place during this period which took its toll in such high number of infants born during this period. In fact, there are at least three other cases, on the critical ill list, with the same symptoms and complaints. One was re- admitted 12 days after birth and another re- admitted 17 days later.

There was an outbreak of diarrhoea in November, and to my mind, an infection which causes mass infant deaths of those born during this period is to be traced to this outbreak and negligence of hospital staff. The Malacca hospital has made a bacteriological study, but to my knowledge, has failed to isolate and identify the bacteria responsible.

The standard of hygiene and the anti-septic measures in the maternity ward of the Malacca Hospital is atrocious, to say the least. Mothers who stayed in the maternity ward complained that babies are bathed one after another without changing the bath water, and during the bathing time, mothers could only pray that their babies are bathed first for they know that if they are bathed later, they would be very dirty. In fact, not only would their babies be dirty, but stand good opportunity of catching whatever infection that is about at that time.

I have also received complaints that feed- bottles in the nursery are not sterilised after used and are in discriminately used for different babies, Cats are also part of the maternity ward fixture of things.

It is clear that whatever the specific cause of the mass death of infants, what bacteria or virus is responsible, the negligence of the Malacca Hospital administration in the maternity ward must shoulder the chief blame.

A public inquiry is urgently needed to go into the full facts, and the government owes the public a full, frank and uncensored disclosure of all the facts and causes and events leading the mass infant deaths.

This is why I had cabled the Health Minister on 3.12.75 calling for the establishment of a Public Inquiry to ascertain whether there had been any hospital negligence and to restore public confidence in the Malacca Hospital.

I do not want to see another repeat performance like the 1973 Malacca Hospital deaths arising from blood poisoning because the breakdown of the autoclave, where the authorities tried at first to deny and later, to hush up the entire scandalous episode.

Even up till today, the Health Ministry has failed to act responsibly and fairly with regard to the victims of the autoclave deaths and to the bereaved families whose loved ones had died because of hospital negligence and maladministration.

On 8th May 1975, the Malacca Coroner, Incik Abdul Kadir bin Musa, in an inquest into the death of Vaithilingam s/c Kuopusamy, 35, on August 11, 1975, after two operations in a single day in a routine stone-in-the bladder operation in the Malacca General Hospital, found that the cause of Vaithilingam’s death, as given in his death certificates, namely, “ Acute Renal Failure” was really caused by “ Septicaemia Contamination of blood characterised by the state of shock.”

The Coroner added:
“From the list of deaths for the month of August, it could be seen that there were 13 deaths as a result of heart and circulatory diseases (which includes renal failure). This is a rather abnormal number of deaths.

“There was no culture done at random to ensure that all intravenous fluids and A.C.D. solution prepared was actually safe to be used, even though it was a notorious fact that this should be done. Further, there were facilities to do so, but still not made used of.

“All the above indicate to my mind one factor only i.e. lack of proper supervision and proper judgement by the administrative staffs.

“As such, I have to force myself to draw the following conclusion:

Cause of death: Septicaemia.
Verdict: (1) Negligence by the administrative staffs of the Malacca General Hospital.
(2) Liability: Open

There can be no clearer indictment and judgment that it is because of the negligence of the Malacca Hospital that caused the mass deaths by blood poisoning in Malacca in July and August 1973.

I had suggested that in view of the Coroner’s clear-out finding putting the entire blame on the Hospital’s negligence, not only in Vaithilingam’s case, but with regard to all such-like cases which exceed the figure of 13 given by the Coroner, the Government should gracefully admit the negligence of the administrative staffs of the General Hospital and make ex-gratia payments to the families of the victims.

Such an ex-gratis payment should not only compensate for the loss of life of the victims, but also include a just and adequate quantum to provide for the dependants of each victim.

The government should not stand on any narrow ground of technicality or legality, whether on the matter of statutory limitation or other, in view of the fact that the slow and cumbrous machinery of government itself had taken close to two years just to produce a coroner’s finding in one such test case.

From the 1973 and 1975 Malacca Hospital deaths, it is clear that there is an appallingly poor leadership in the administrative level in the Ministry of Health. Top Ministry officials, from the Director of Medical Services Downwards, instead of globe-trotting and attending international conferences, would do better and benefit the people more if they tour the hospitals regularly to ensure that a minimum of hospital administrative competent is maintained.

Another cause intimately related to the sharp drop of administrative competence, therefore consequent increase in the incidence of negligence and incompetence, is the deplorable system of promotion based on grounds other than merit! Such a promotion system not only demoralises the entire administration and service, undermine competence and efficiency, but is the main cause for the departure from the medical and health service of dedicated and committed professional officers.

I believe that the Malacca Hospital is no better or no worse to other hospitals in Malaysia, which means that in other hospitals, such unnecessary and negligent deaths also occur. The only difference is that in Malacca, we in the DAP managed to prevent them from being hushed up.

The substance of this motion, therefore, does not concern Malacca alone, but all hospitals throughout the country. Parliament is entitled to an assurance that there would be a public inquiry into the 1975 Malacca Hospital death which would permit a dull disclosure of the facts and causes of the infant deaths. If the Minister can order the holding of such a public inquiry, I am prepared to withdraw this motion as I have nothing against him personally.