The Sunday Times Plus Section

23th July 2000

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Minutes after vaccination the baby died. What went wrong?

Death by vaccination

By Hiranthi Fernando

The death of an infant is always terribly sad. The needless death of a healthy infant is truly tragic.

from the family album Just fourteen months old, Navodhya Jayakody was a happy, healthy little toddler. Hers was to be the nightmare that every parent dreads. Taken to the Kadawatha Nursing Home last Saturday for a routine vaccination, the MMR (Measles, Mumps, Rubella) she was brought back home three days later in a tiny coffin.

What went wrong? This is the question that Navodhya's distraught parents and indeed many others around the country are asking. How could things go so tragically wrong?

"My child was perfectly healthy. I took her to the nursing home around 11.30 a.m on the 15th for the MMR vaccine as the doctor had told us," wept Navodhya's mother, Shirani Jayakody.

"I was given No. 27, so we had to wait. As my daughter was hungry, I fed her two biscuits and she also drank some water. She was walking about cheerfully when we were called in at around 12.50."

The mother related how the doctor at the nursing home had examined the baby and given her a chit to pay Rs. 475 to the cashier.

"I paid for my child's death warrant," Shirani sobbed. They were then called into the room where a nurse filled a syringe from a vial and placed it on the doctor's table. Shirani recalled that it was a small brown bottle. The doctor injected the baby's arm and Shirani rubbed it down with a swab of cotton wool and left the room.

"Just then the nurse came out and told me the doctor wanted us to wait a while," Shirani said.

"She gave me a prescription for a powder in case Navodhya developed a temperature. When I purchased the powder from the dispensary, it was around 1 p.m. I was about to sit on a bench to wait for the doctor, when I noticed the baby's eyes closing. Her lips began turning blue. I did not even have time to think before she suddenly collapsed and went limp in my arms. I screamed for the nurse to call the doctor but as I turned round, he was beside me."

She said, "The doctor took the child from me and went into a room where there were some nurses and another doctor. Cylinders of oxygen were also taken in. Although I followed, I was not allowed in. I did not know what they were doing inside. I was all alone and desperate.

"Seeing someone I knew from my village I asked her to call my husband but she went off without helping me. When I told the receptionist my child was seriously ill and asked for a call, they told me no private calls were permitted. Now truly worried and frightened, I shouted and banged on the glass of the room. Finally I managed to get a call to my husband."

Shirani's husband Chandimal arrived in five to ten minutes. He too tried to enter the room where the baby was being treated, but with little success.

He then called his brother on a mobile phone and asked him and his mother to rush to the hospital with a van to take the child to Colombo.

Insisting that the doctor who administered the injection accompany them, they left for the Lady Ridgeway Hospital.

"Although they continued giving the baby oxygen, I do not think she was alive then," Shirani said. They arrived at the hospital around 2 p.m. "The doctor handed the child to me to alight from the van. She was like ice then. He then took her into the Emergency Ward of the hospital. However, it was no use.

"The doctor there said my baby had died," Shirani said.

The baby's body was kept at the hospital that night and was taken to the mortuary the next day. An inquest was held and also a post-mortem on Tuesday after which the body was released to the parents. Navodhya's funeral was held on Wednesday evening amidst a large gathering of people from their village -Ihala Karagahamuna.

Was there a mix-up? This is the question that haunts Navodhya's parents. Shirani alleges that the drug for the injection was from a brown bottle though the bottle produced by the doctor at the inquest was a white one.

On the request of the Judicial Medical Officer, the parents purchased a vial of MMR vaccine from a pharmacy and handed it over at the inquest. This was a white bottle.

Shirani is convinced that her child was given the wrong injection. "The doctor did not even look at the vial the nurse had brought," she said. "He left it all to her.

He just gave the injection, and when he was asked at the inquest who the nurse was, he did not even remember her name."

"I telephoned my uncle as we left for Colombo, asking him to collect the injection vial and syringe from the nursing home and bring it to Colombo," Chandimal Jayakody said.

"However, the hospital staff had told him the room was locked. Chandimal said that apart from the vaccination spot, the baby had two more injection marks on the arm and elbow of the other hand.

Dr. J.C. Herath who conducted the post-mortem said the cause of death cannot be determined from the findings of the post-mortem alone and hence has been noted as 'Under Investigation'.

"I have taken blood for toxicological analysis and specimens of skin and muscle from the injection sites and we now have to wait for the report from the Government Analyst and the pathologists," he said.

Dr. Herath said the vaccine which is in powder form has to be mixed with a solvent which is provided in reputable brands. The MMR vaccine is a live vaccine which is grown in a medium.

Meanwhile, the doctor who administered the vaccine said, "Although we know or can presume what the reasons for the death are, the matter is under investigation and we have to wait for the results."

Navodhya's parents' sorrow is mingled with regret.

"We want a proper investigation to prevent this tragedy happening to other parents. We cannot bring our child back to life but at least we can prevent another child suffering the same fate."

Investigations on

The Director, Private Health Sector Development, at the Ministry of Health, Dr. Amal Harsha de Silva is conducting the inquiry into the death of Navodhya Jayakody. Dr. de Silva said he had visited the hospital, taken statements and necessary material and details from the hospital.

According to Dr. de Silva, the post-mortem cannot reveal much. "Usually the MMR is not identified with this type of reaction. The vaccine consists of a powder and a diluent," he says.

He says there is a possibility that the diluent could get mixed up with a similar drug. Meanwhile, he has instructed that the batch of vaccines remaining in the hospital should not be used. More tests are being carried out on the samples of vaccines.

"We have to establish the cause of death and whether there has been any fault on the part of the hospital. The Minister is also very concerned about this incident and wants a proper investigation to be conducted. When administering a vaccine, particularly to small children utmost care is necessary on the part of the medical officer," he said.

Dr. de Silva added that the Nursing Homes Act of 1943 is inadequate to control this type of incident, but was hopeful that a new Bill on private medical institutions which has been presented in Parliament, if passed would help.

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