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Blunders by two doctors, nurse led to living baby being declared dead

Monday July 9 2018

 baby Joseph Ngugi

Family members point to the spot where baby Joseph Ngugi was finally buried after doctors erroneously pronounced him dead, only for him to wake up minutes before his burial and die 24 hours later. PHOTO | FILE | NATION MEDIA GROUP 

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Shocking details have emerged of the events that saw two doctors and a nurse at Kiambu Level Five Hospital declare a 20-day-old baby dead and issue a burial permit to the parents when he was still alive.

Joseph Ngugi was admitted to the hospital after being referred from Ngewa Health Centre in Githunguri but was declared dead on June 27 and his treatment stopped before the “corpse” was released to the parents around 4.30pm.

His parents dug a grave at their Lioki village home but the baby coughed and began crying just before the burial.

Ngugi died 24 hours later and a second burial permit was issued at Gatundu Level Five Hospital where he had been transferred from Kigumo Hospital where his mother Margaret Ahoi had taken him.


The family now insists the baby would still be alive had the doctors not made the blunder.


Kiambu Health executive John Murega,  Chief Health Officer Andrew Toro, Hospital Superintendent Jesse Ngugi, two resident doctors and a nurse appeared before the Assembly Health Committee.

A preliminary report on an internal investigation on the matter, which was read to the Nyathuna MCA Edward Kinyanjui-led committee, also exposed glaring mistakes on the hospital system and individual failure.

Ms Ahoi said she took the baby to Ngewa Health Centre in the morning but was referred to Kiambu Hospital. She was informed by doctors the following morning that her son had died.

The woman said she watched as nurses undressed the baby and called a mortuary attendant to pick the body.

However, the mortician declined to do as told because the oxygen machine was still attached to the boy.


“When we arrived home, he coughed and cried. We uncovered him and saw  blood oozing from the point he had been injected. Were it not for the delay on our way home, my baby would have been buried alive,” Mrs Ahoi said.

One of the doctors who appeared before the assembly committee on Thursday, said she  certified the baby dead after attempts to resuscitate him failed.

The doctor said she counter-checked with a colleague before signing the file.

She said she later noticed the baby gasping and informed relatives though she did not record the information.

The nurse who was the last to handle the baby, said when her shift began in the afternoon, she received an oral report that Ngugi, who still had oxygen attached to him had been unsuccessfully resuscitated and “after observing him, I saw no sign of life”.

“Since the baby had been certified dead, it was a body to me. The relatives insisted on going with the body home so I directed them to the billing office,” she said, adding that she was the one who disconnected the oxygen tank from the boy.


Dr Ngugi faulted the two doctors for concluding that the patient was dead, saying they should have consulted their seniors first.

“In situations where things are not clear, you are supposed to ask a colleague to be able to ratify your findings and come into an agreement that the patient is dead,” he said.

Dr Ngugi said the nurse violated clinical guidelines by releasing the body to the relatives without first releasing it to the mortuary, saying it led to non-documentation on who made the declaration of the death.

“Once a patient is certified dead, the body is released to the mortuary for documentation and the last procedures. The family can decide if the body should remain in the mortuary,” Dr Ngugi said.

According to the internal investigation read to the committee by Dr Maxwell Murage, who is also the county director for medical services, the death certificate was not cancelled.

It means the hospital records show that the baby died at midnight and the body was released to the family at 4.30pm.

Dr Murage said when the baby showed signs of life, the development was never documented in his file.