A review report published by the Ministry of Health on the death of Fathmath Mishka Mohamed, Maldives’ youngest COVID-19 victim, reveals numerous occasions in which established standards were ignored.
The review’s findings revealed numerous instances of negligence and failure to respond to the matter, beginning with when she tested positive.
According to the review report, the sample was taken from Mishka on May 28 when she began having COVID-19-like symptoms. Her parents were notified two days later that she had tested positive for COVID-19. In accordance with policy, Mishka’s parent was asked if they wanted a doctor’s consultation, and even though the parent’s request for a consultation was put on the sheet, no consultation was provided, nor was the information updated to the Outbreak (OB) system as needed.
The Care Cluster hotline is also mandated by the standard protocol to make daily calls and check on the condition of children under the age of 15 years. However, no contact was made even after two days.
Mishka’s parents called the Health Protection Agency’s (HPA) call center at 14:20 on May 31 to report that she had developed a high temperature and cough. They also claimed that she was unable to eat properly and was exhausted. At 15:53, a doctor from DMRT called for a general consultation and advised Mishka to continue taking her existing medicine and to call back if any new issues arose. Mishka’s family contacted the Call Centre again at 21:06 due to continuing difficulties, and they were informed that Mishka’s condition was deteriorating.
According to the findings, at 21:53, a doctor from DMRT attempted but failed to reach the parent. Despite being unable to contact the parent, it was marked as “attended” on the sheet. After missing the doctor’s call, the parent called the Call Center again at 22:06 to alert them that Mishka was in respiratory distress.
The doctor contacted them around 22:33 to inquire about her status. Mishka’s family provided thorough information about her, including the fact that she is a COVID-19 positive patient who was having respiratory difficulties for a day. They went on to say that she was a special needs child who had difficulty communicating her condition, which was subsequently forwarded to the two clusters assigned to dispatch ambulance – DMRT and CMAT – neither of which had requested that an ambulance be dispatched.
The findings revealed that Mishka’s parents had called the Call Center five times between 23:16 and 23:33 and in one call, they noted that her condition was deteriorating and that she had fainted with blood from her nose and mouth. The Call Center repeatedly told her parent that an ambulance was on its way; however, records show that it was never dispatched.
Due to the failure to dispatch an ambulance, a member of Mishka’s family went to Dharubaaruge at 11:27 p.m. the same night, and the HEOC’s facility management cluster notified EMS of the situation.
Following the ambulance’s delay, a member of Mishka’s family went to the HEOC headquarters in Dharubaaruge. After that, at 23:32, HEOC’s Facility Management Cluster notified EMS of the need for an ambulance. After a two-hour wait, at 23:33, EMS called the parent to inform them that an ambulance had been dispatched.
According to the health ministry, emergency services were activated, and the 10-year-old was brought to the hospital within 10 minutes of being notified. Mishka was declared dead at 12:10 a.m. on June 1 after more than two hours of waiting for an ambulance.
According to the report, the incident was not reported as an emergency, and emergency healthcare protocols were not initiated. It took two hours and 26 minutes for an ambulance to be activated after Mishka’s condition was recorded as an emergency.
In addition to the timeline of events and results, the report detailed adjustments made to the system to prevent such a sad tragedy from occurring again. These measures involve attentively monitoring the calls, categorizing them effectively to determine levels of emergency, and reducing the number of coordination points in the process while dealing with an emergency.
The Health Ministry has stated that they will take the required actions in response to the report’s findings.
The Human Rights Commission of the Maldives (HRCM) and the People’s Majlis are also looking into the death.