SINGAPORE - She was only three years old, and she was undergoing her second liver transplant.
Unfortunately, she developed complications after her transplant and died.
Wednesday was the coroner's inquiry into the death of Nadia Abdullah, who was born with a liver condition.
The coroner's court heard that Nadia had a history of biliary atresia - a congenital lack of bile ducts to drain bile from the liver.
She also had a medical history of beta-thalassaemia trait and iron-deficiency anaemia.
Nadia, who was born on Feb 7, 2006, underwent an operation about a month later to allow the drainage of bile from her liver, but it was not successful.
Her liver functions then began to fail. About two years later on April 10, 2008, her mother, Ms Norhayati Amir, donated part of her liver to her.
The liver transplant was carried out at the National University Hospital (NUH).
But various complications occurred - anaemia was noted about 18 months after the transplant, among others.
Soon, she needed a second transplant. She was put on the waiting list for a cadaver liver - liver donated by a donor who is brain-dead.
Within months, a suitable and matching liver was found on the evening of Jan 13, 2010. The donor was a 30-year-old healthy woman, who suffered a stroke of the brain.
Nadia was admitted into NUH again the next day, for a scheduled second liver transplant.
Did spat with doctor lead to toddler's death?
Did spat with doctor lead to toddler's death?
Professor K Prabhakaran, the head of department of Paediatric Surgery of NUH, performed the operation.
Dr Dale Lincoln Loh Ser Kheng, a senior consultant in the Department of Paediatric Surgery at NUH, assisted him together with other surgeons.
The operation went well, but Nadia's cardiovascular status became unstable.
She later became unresponsive and remained in the paediatric intensive care unit (ICU) of NUH until her death on Jan 29, 2010 - about 15 days after the second transplant.
But Ms Norhayati, 28, who is a nurse, was concerned over the cause of death of her daughter. She raised several issues.
She was concerned over whether Dr Loh had performed the second transplant properly because she had a spat with him in the morning of the operation.
This was over the issue of consent - Dr Loh had obtained the consent for the second liver transplant from Nadia's grandmother instead of her, as Ms Norhayati wasn't in NUH at that time.
When Ms Norhayati was asked to go to NUH urgently the next morning to give her consent, a quarrel ensued.
The quarrel was between her and Dr Loh over the urgency of the issue and why she was not asked for her consent the evening before.
Dr Loh confirmed that "he did not do anything knowingly" which would cause Nadia's death.
Also noted was his role as one of the assisting surgeons and not as the main surgeon.
Ms Norhayati was concerned over whether NUH had done any proper checks to ensure that the donor's liver was a suitablematch to Nadia.
Dr Loh confirmed that the liver was an appropriate and suitable match - the donor had the same blood type and was below 40 years old, among others.
An independent expert, Associate Professor Loh Tsee Foong, the head and senior consultant from the Children's ICU of KK Women's and Children's Hospital, added that the complications Nadia had suffered were not unexpected in liver transplant.
Apart from the frequency of monitoring of ammonia level, the overall care and management given to Nadia was reasonable, he said.
Ms Norhayati said she would not have agreed to the second transplant if she had been informed that the donor was lupus positive.
But an independent expert, Dr Ravishankar K Diddapur, consultant surgeon from the Specialist Surgery, clarified that a donor who is lupus positive is not known to affect a recipient and screening for lupus antibody is not recommended as the risk is considered small.
NUH also clarified in a report that the screening for lupus positivity was not one of the routine blood investigations in donor screening.
Ms Norhayati asked how Nadia had caught the superbug MRSA.
As Nadia had multiple admissions into the hospital, Dr Ravishankar said it was difficult to ascertain when and how she had got the infection.
Ms Norhayati asked if the cardiopulmonary resuscitation (CPR) done on Nadia could have caused bleeding in her brain and if the bleeding could have been managed medically.
Prof Loh said in his report dated May 7 this year that it is possible that CPR may result in intracranial bleeding, but it would be an unintended side effect.
He also stated that the bleeding area in the brain was small and did not appear to cause a significant pressure on the brain and neurosurgical intervention is more likely to be harmful than of benefit to Nadia.
Police do not suspect foul play in Nadia's death.
Before State Coroner Imran Abdul Hamid presented his findings, he offered his condolences to Ms Norhayati.
He then addressed her concern over the spat.
He said: "Despite the spat, it has not affected the transplant itself. The transplantation of the liver was done without any technical issue and did not bear cause of death."
But he also noted that it would be beneficial if Dr Loh had spoken to Ms Norhayati directly instead of to Nadia's grandmother.
He also noted that "a single parent's responsibility can be tremendous".
When the liver fails
When the liver fails
Nadia died from multi-organ failure as the liver graft had failed to thrive and complications arose. The unstoppable events had then led to Nadia's death, he said.
Liver failure happens when large parts of the organ become damaged beyond repair and it is no longer able to function.
It is life-threatening and demands urgent medical care.
Most often, liver failure occurs gradually over many years.
But a rare condition known as acute liver failure occurs in as little as 48 hours and can be hard to detect initially.
The most common causes of chronic liver failure include hepatitis (B and C), cirrhosis (irreversible scarring of the liver), hemochromatosis (an inherited disorder that causes the body to absorb and store too much iron) and long-term alcohol consumption.
In children, it is caused by biliary atresia, a condition which begins soon after birth, where the bile ducts fail to develop normally and are unable to drain bile from the liver.
Early symptoms of liver failure include nausea, loss of appetite, fatigue and diarrhoea. These can develop into jaundice, mental disorientation or confusion and even coma "should the condition worsen".
For liver failure resulting from long-term deterioration, the initial treatment is to save whatever part of the liver that is still functioning.
If this is not possible, then a liver transplant is required.
As of March, more than 500 patients with organ failure are still waiting for donor organs.
Of these, 448 are on the National Kidney Transplant waiting list while on dialysis, while 28 are in the queue for new livers, six for hearts and 22 for corneas.
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