Ob Claims - Sogh 2011

A Study of OB Claims

Society of OB/GYN Hospitalists

September 24, 2011

Darrell Ranum, JD, CPHRM

Regional Vice President, Patient Safety

OB Advisory Board / 2

Introduction

1. Introduction to Executive Information Systems

2. Overview of OB Closed Claim Studya. Number of neonatal and maternal OB claims

b. OB claim frequency

3. Injury Severitya. Neonatal injuries

b. Maternal injuries

4. Infant OB Claims

5. Maternal OB Claims

6. Discussion


Executive Information Systems

• Developed by CRICO/Strategies, the Harvard health care system’s insurance captive and RM program

• Provides an extensive taxonomy for coding the clinical aspects of medical malpractice cases

• Today’s studies include only closed claims


OB Patient Ages by Loss Year

Infant claims=211

Maternal claims=96

Patients' Ages for Events 2000-2010

Claim Count

Unknown 30Neonatal (< 1 month) 210First Year (1–11 months) 1Teenager (10–17 years) 6Young Adult (18–29 years) 114Adult (30–64 years) 76 *TOTAL 437


The Doctors Company OB/GYN Claim Frequency by Report Year

Report Year Exposure Claim Count Frequency

2000 569 153 27%2001 680 152 22%2002 828 192 23%2003 847 200 24%2004 743 149 20%2005 742 151 20%2006 805 131 16%2007 886 147 17%2008 971 156 16%2009 1,162 184 16%

Notes- Exposure is adjusted to a full-time, mature equivalent basis.- Exposure is not adjusted to a base territory equivalence.- Claim counts have been developed to ultimate levels.- Frequency is equal to ultimate claim counts divided by exposure.- Excludes experience for tail policies and certain large groups and schools.


OB Injury Severity

1. Neonatal claims comparing 2000–2004 with 2005–2009 time periodsa. NAIC severity index categories (low, medium,

and high)

2. Maternal claims comparing 2000–2004 with 2005–2009 time periodsa. NAIC severity index categories (low, medium,

and high)


Injury Severity for Neonatal Claims

Neonatal Injuries by Severity Category

2000-2004 Claim Count

2000-2004 Percentage



High 140 85.4% 39 73.6%Medium 23 14.0% 10 18.9%Low 1 0.6% 4 7.5% *TOTAL 164 53


Injury Severity for Maternal Claims

Maternal Injuries by Severity Category





High 31 28.7% 19 19.8%Medium 55 50.9% 41 42.7%Low 22 20.4% 36 37.5% *TOTAL 108 96


Moving Beyond the Numbers

1. Numbers are interesting but they do not tell the stories of the cases they represent

2. We need to drill deeper to learn about the underlying causes of patient harm

3. We can study these cases using a variety ofdata points:• Allegations• Risk Management Issues ( Contributing factors )• Diagnoses• Procedures• And many more


Neonatal OB Claims


Neonatal OB Claims

1. Most common allegations

2. Most common risk management issues (contributing factors)

3. Most common neonatal injuries

4. Neonatal injuries by allegation

5. Observations


Neonatal OB Allegations: 2000–2004 Versus 2005–2009

Infant OB Claims by Major Allegation

Claim Count

2000-2004 %

Claim Count

2005-2009 %

DELAY IN TREATMENT OF FETAL DISTRESS 50 30.5% 14 29.8%IMPROPER PERFORMANCE OF VAGINAL DELIVERY 39 23.8% 8 17.0%OBSTETRIC-RELATED TREATMENT - OTHER 19 11.6% 4 8.5%IMPROPER CHOICE OF DELIVERY METHOD 15 9.1% 4 8.5%IMPROPERLY MANAGED LABOR - OTHER 12 7.3% 2 4.3%IMPROPER MANAGEMENT OF PREGNANCY 9 5.5% 5 10.6%DELAY IN DELIVERY (INDUCTION/SURGERY) 9 5.5% 3 6.4%IMPROPER PERFORMANCE OF OPERATIVE DELIVERY 4 2.4% 2 4.3%


Neonatal OB RM Issues:2000–2004 Versus 2005–2009

Note: Most claims have multiple Risk Management issues

OB Infant Risk Management Issues

Claim Count

2000-2004 %

Claim Count

2005-2009 %Selection/management of therapy—labor & delivery 93 62.8% 15 38.5%Lackof or inadequate assessment—note clinical info 40 27.0% 6 15.4%Staff training/education 35 23.6% 4 10.3%Patient monitoring—physiological 34 23.0% 7 17.9%Communication among providers—pt condition 31 20.9% 5 12.8%Fail to rule out abnormal finding 22 14.9% 3 7.7Fail/delay ordering diagnostic test 22 14.9% 6 15.4%Inadequate consent—tx option 21 14.2% 3 7.7Patient assessment issues—other 17 11.5% 2 5.1Poor technique—other 14 9.5% 4 10.3%


Neonatal Injuries 2000–2009

About 20% of all claims result in indemnity

Neonatal Injuries 2000-2009Claim Count

Neonatal Injuries 2000-2009 for Claims with Indemnity >$100

Claim Count

Average Indemnity

Average Expense

ORGAN DAMAGE 70 ORGAN DAMAGE 31 1,058,613 185,282NERVE DAMAGE 58 NERVE DAMAGE 22 421,878 104,538DEATH 54 DEATH 22 329,957 64,711AGGRAVATED/WORSENED 4 HEMORRHAGE 3 705,000 88,750HEMORRHAGE 4 BIRTH INJURY/DEFECT 1 475,000 84,042BIRTH INJURY/DEFECT 3 FRACTURE OPEN/CLOSED 1 32,500 98,198FRACTURE OPEN/CLOSED 3 *TOTAL 80 649,749 123,946 *TOTAL 211 38% of these claims had indemnity


Observations Regarding Neonatal Claims

• The top three patient injuries make up about 86 percent of all injuries (see slide 14)

• The six most common risk management issues are seen less frequently as a contributing factor in the 2005–2009 time frame (see slide 13)

• The percentage of high severity patient injuries is slightly lower in recent years (see slide 7)

• Claim frequency (number of claims) is lower (see slide 5)


Neonatal Claims by Procedure

Neonatal Claim Procedures 2000-2010Claim Count

ZZZ - NONE/NULL 7573.59 - MANUALLY ASSISTED DELIVERY 5774.99 - CESAREAN-SECTION UNSP 2772.79 - VACUUM EXTRACTION 1872.71 - VACUUM EXTRACTION - EPISIOTOMY 764.0 - CIRCUMCISION 672.29 - VACUUM EXTRACTION OTH 672.1 - LOW FORCEPS WITH EPISIOTOMY 472.0 - LOW FORCEPS OPERATION 372.4 - FORCEPS ROTATION OF FETAL HEAD 374.0 - CLASSICAL C-SECTION 372.21 - MID FORCEPS OP WITH EPISIOTOMY 275.34 - FETAL MONITORING OTH 273.4 - MEDICAL INDUCTION OF LABOR 199.29 - INJ/INFUS OTH THER/PROPHY SUB 1 *TOTAL 217


Neonatal Injuries (Organ Damage, Death, and Nerve Damage) by Allegation

Neonatal Nerve Damage by Allegation 2000-2009Claim Count

0212 - IMPROPER PERFORMANCE OF VAGINAL DELIVERY 380211 - IMPROPER CHOICE OF DELIVERY METHOD 120214 - IMPROPER MANAGEMENT OF PREGNANCY 20217 - IMPROPERLY MANAGED LABOR - OTHER 20218 - IMPROPER PERFORMANCE OF OPERATIVE DELIVERY 2

Neonatal Death by Allegation 2000-2009Claim Count

0215 - DELAY IN TREATMENT OF FETAL DISTRESS 260219 - OBSTETRIC-RELATED TREATMENT - OTHER 70212 - IMPROPER PERFORMANCE OF VAGINAL DELIVERY 40216 - DELAY IN DELIVERY (INDUCTION/SURGERY) 40211 - IMPROPER CHOICE OF DELIVERY METHOD 3

Neonatal Organ Damage by Allegation 2000-2009Claim Count

0215 - DELAY IN TREATMENT OF FETAL DISTRESS 350214 - IMPROPER MANAGEMENT OF PREGNANCY 70216 - DELAY IN DELIVERY (INDUCTION/SURGERY) 70217 - IMPROPERLY MANAGED LABOR - OTHER 60219 - OBSTETRIC-RELATED TREATMENT - OTHER 6


Infant Brain Damage and Death Cases

In half of neonatal brain damage and death cases, Delay in Treatment of

Fetal Distress was the major allegation.

Why?


Observations in Neonatal Death and Brain Damage Cases

Physicians postponed c-sections Attempted other methods–vacuum delivery Waited to see if symptoms improve

Physicians were slow to respond to callsfrom nurses

Asked nurses to try more interventions Physicians arrived later than requested


Observations in Neonatal Death and Brain Damage Cases (continued)

Communications failed at critical times Nurse notified physician of decelerations, physician

expected nurse to call again if no improvement. Nurse expected physician to come to the hospital.

Nurse communicated information about fetal distress. Physician did not recognize the urgency of the situation/denies receiving info


Observations in Neonatal Death and Brain Damage Cases (continued)

Inexperienced nurses Failed to recognize non-reassuring fetal heart

rate tracings Delayed assessment of the patient at a critical time

• Following a MVA

• When admitted for preeclampsia


Observations in Neonatal NerveDamage Cases

Nerve damage case allegations Improper choice of delivery method Improper performance of delivery Inadequate consent


Observations in Neonatal Nerve Damage Cases (continued)

Managing the pregnancy leading up to labor and failure to address: History of large babies or obese mothers and failure to

adequately assess sizes of fetuses History of gestational diabetes, but no documentation

of GTT History of shoulder dystocia, but no discussion of risks

of vaginal deliveries or C-section options Allowing more than one week post dates for

suspected large infants



Management of labor and technique Allowed prolonged labor with large infants Multiple attempts of vacuum extraction with

failure to progress Alleged improper technique for addressing

shoulder dystocia Documentation indicating fundal pressure rather

than suprapubic pressure


Behaviors of mothers Non-compliant with diabetic diets Refused to consider c-sections, even with prolonged

second stage of labor or other risk factors Delayed arriving at the hospital until almost ready

to deliver



Process of Care DiagramFor Neonates


Process of Care Diagram

• Look at labor and delivery from thepatient’s perspective

• The process of care is represented in a diagram• The diagram incorporates all of the neonatal OB

cases in the study• Use the diagram to overlay your processes

Could your processes potentially fail? Do your processes have the same weaknesses as the

cases in the diagram?


Tools for Reducing Birth Injury Cases

Summary Look for tools to stimulate discussion Tools help physicians and staff look at system

issues objectively• No guilt related to the cases in the diagrams

• No one needs to be defensive because these are not their cases

Discussions foster collaboration between nursesand physicians

Help them solve the system problems together


Maternal OB Claims


Maternal OB Claims

1. Most common allegations

2. Most common risk management issues (contributing factors)

3. Most common maternal injuries

4. Maternal injuries by allegation

5. Maternal claims by procedure

6. Maternal procedures by risk management issue

7. Summary of maternal injury cases


Maternal Claims by Allegation

Maternal OB Claims by Allegation 2000-2004 Claim Count




OBSTETRIC-RELATED TREATMENT - OTHER 20 18.3% 21 24.1%RETAINED FOREIGN BODY 13 11.9% 5 5.7%FAILURE TO DIAGNOSE 11 10.1% 2 2.3%IMPROPER PERFORMANCE OF SURGERY 10 9.2% 5 5.7%DELAY IN TREATMENT OF FETAL DISTRESS 8 7.3% 9 10.3%IMPROPER PERFORMANCE OF VAGINAL DELIVERY 7 6.4% 7 8.0%IMPROPER MANAGEMENT OF PREGNANCY 7 6.4% 10 11.5%DELAY IN DIAGNOSIS 7 6.4% 5 5.7%


Maternal Claims by Risk Management Issue

Maternal Claims by RM Issue


2000-2004

Percent


2005-2009

PercentSelection/management of therapy—labor & delivery 23 22.3% 7 9.0%Staff training/education 18 17.5% 9 11.5%Retained foreign body—surgical 13 12.6% 5 6.4%Lack/inad assessment—note clinical info 13 12.6% 7 9.0%Fail/delay ordering diagnostic test 12 11.7% 11 14.1%Patient monitoring—physiological 12 11.7% 7 9.0%Seek other provider due to dissatisfaction 12 11.7% 0 0.0%Fail to establish differential diagnosis 11 10.7% 9 11.5%Communication among providers—patient condition 11 10.7% 9 11.5%Inconsistent documentation 10 9.7% 2 2.5%No RM issues identified 10 9.7% 12 15.4%


Maternal Injuries 2000–2009

Maternal OB Injuries 2000-2009Claim Count

Maternal OB Injuries 2000-2009 for Claims with Indemnity >$100

Claim Count

Average Indemnity

Average Expense

EMOTIONAL TRAUMA 52 EMOTIONAL TRAUMA 15 194,421 67,071DEATH 19 FOREIGN BODY 10 25,880 15,052FOREIGN BODY 18 DEATH 6 283,333 250,140HEMORRHAGE 17 HEMORRHAGE 4 342,375 68,235AGGRAVATED/WORSENED 10 LOSS - TOTAL 3 193,333 47,589INFECTION 8 ORGAN DAMAGE 2 725,000 321,944PUNCTURE/PERFORATION 5 AGGRAVATED/WORSENED 2 24,500 21,817NERVE DAMAGE 5 BURN 2 9,250 1,658LOSS - TOTAL 5 GI DYSFUNCTION 2 77,500 59,766ORGAN DAMAGE 4 INFECTION 2 656,040 149,319LACERATION/TEAR 4 LACERATION/TEAR 2 197,500 22,589GI DYSFUNCTION 4 PREGNANCY UNWANTED 2 30,750 18,091HERNIATION/RUPTURE 4 DEHISCENCE 1 29,999 55,668PREGNANCY UNWANTED 3 EMBOLISM/THROMBOSIS 1 225,000 185,998SCARRING 3 NERVE DAMAGE 1 84,000 18,294HEMATOMA 3 PUNCTURE/PERFORATION 1 20,000 26,511FISTULA 3 *TOTAL 55 235,631 82,727EMBOLISM/THROMBOSIS 3 30% of claims had indemnity


Maternal Injuries by Allegation

Maternal Emotional Distress Injury by Allegation 2000-2009

Claim Count

DELAY IN TREATMENT OF FETAL DISTRESS 12IMPROPER MANAGEMENT OF PREGNANCY 11OBSTETRIC-RELATED TREATMENT - OTHER 6DELAY IN DELIVERY (INDUCTION/SURGERY) 4IMPROPER PERFORMANCE OF SURGERY 3

Maternal Death by Allegation 2000-2009Claim Count

OBSTETRIC-RELATED TREATMENT - OTHER 6FAILURE TO DIAGNOSE 5IMPROPERLY MANAGED LABOR - OTHER 2TREATMENT - OTHER 1IMPROPER PERFORMANCE OF VAGINAL DELIVERY 1

Maternal Retained Foreign Body injury by Allegation 2000-2009

Claim Count

RETAINED FOREIGN BODY 17OBSTETRIC-RELATED TREATMENT - OTHER 1


Maternal Claims by Procedure

Maternal Claims by Procedure 2000-2009Claim Count

ZZZ - NONE/NULL 8074.99 - CESAREAN-SECTION UNSP 4873.59 - MANUALLY ASSISTED DELIVERY 2175.69 - REPAIR OB LAC CURRENT OTH 766.39 - BILAT DEST FALLOPIAN TUBES 573.6 - EPISIOTOMY 469.02 - D&C FOLLOW DELIVERY/ABORTION 372.1 - LOW FORCEPS WITH EPISIOTOMY 372.79 - VACUUM EXTRACTION 374.1 - LOW CERVICAL CESAREAN SECTION 366.29 - BILAT ENDOS DEST-FALL TUBE 269.09 - DILATION AND CURETTAGE 273.4 - MEDICAL INDUCTION OF LABOR 2


Procedures by RM Issue

Manually Assisted Delivery Procedure by Risk Management Issues 2000-2009

Claim Count

Sel/mgt ther—labor & delivery 5Possible technical problem 3No RM issues identified 3Pt monitoring—physiological 2Tech performance—other 2

Repair OB Lac Current Other ProcedureClaim Count

Staff training/education 1Patient bizarre behavior 1Seek oth prov due to dissatisf 1Lack/inad assessment—other 1Poor patient rapport 1

Cesarean-Section Procedure by Risk Management Issue 2000-2009

Claim Count

Staff training/education 14Ret foreign body—surgical 13Sel/mgt ther—labor & delivery 11Lack/inad assessment—other 9Commun among prov—pt condition 8


Examples of Maternal Injuries

1. Emotional trauma

2. Foreign body

3. Death


Maternal Injuries–Emotional Trauma

1. Infant death=13 of 15 casesa. In one case the mother also experienced

HELLP syndrome

2. No consent for infant autopsy=one of 15 cases

3. No consent for circumcision=one of 15 cases


Maternal Injury–Foreign Body

1. Sponge left following c-section=seven of 13 cases

2. Gauze pads left in vagina following vaginal births=five of 13 cases

3. Fetal scalp electrode retained=one of 13 cases


Maternal Injury–Death

1. Bleeding after delivery=three of six cases

2. Arrested at home before labor=one of six cases• Undiagnosed pre-eclampsia or pulmonary edema

which is more indicative of arrhythmia development and arrest than pre-eclampsia

3. Arrested in hospital=one of six cases• Dehydration and electrolyte imbalance due to

undiagnosed diabetic ketoacidosis

4. Amniotic fluid embolism=one of six cases• Seizure during delivery


Maternal Injuries–Hemorrhage

1. Continued bleeding after c-sections=three offour casesa. One case due to abnormal coagulation (studies

conducted after emergency hysterectomy)

2. Continued bleeding after vaginal delivery=one of four cases

3. Plus three hemorrhages resulting in death(slide 41)


Maternal OB Claim Observations

1. Most maternal injuries are emotional due to the death or serious injury of their neonates

2. The majority of physical injuries to mothers are not severea. Foreign bodies retainedb. Infectionsc. Other complications of surgery

3. Injuries to mothers have the potential to be catastrophica. Hemorrhageb. Brain damagec. Death


Questions/Discussion:

Is your experience consistent with this data?

If not, what patient injuries are you seeing?

What are your priorities for improving patient safety?


The Doctors Company

Our Mission is to advance, protect, and reward the

practice of good medicine.

[email protected], ext. 5186

A Study of GYN Claims

Society of OB/GYN Hospitalists

September 24, 2011

Darrell Ranum, JD, CPHRM

Regional Vice President, Patient Safety


Introduction

• Number of claims from 2001–2010=370• Claims by patient age • Most common allegations• Most common risk management issues (factors

contributing to patient injury)• Types of injuries


Introduction (continued)

• Injury severity• Body part• Admitting diagnosis• Final diagnosis• Procedures• Observations


GYN Claims by Patient Age


GYN Patient Ages by Decade


Allegations Sub-Categories–Top 3

1. Surgical treatment1. Improper performance of surgery–53%

2. Improper management of surgical patient–7%

3. Retained foreign body–6%

2. Diagnosis-related1. Failure to diagnose–8%

2. Delay in diagnosis–5%

3. Medical treatment (non-OB)1. Improper performance of treatment or procedure–3%

2. Improper management of treatment course–2%


Risk Management Issues–Top 6

• Technical performance–42% Possible technical problem Poor technique Misidentification of anatomical structure

• Patient assessment issues–28% Failure or delay ordering diagnostic test Failure to establish a differential diagnosis Failure to note clinical information

• Patient factors–24% Seek other providers due to dissatisfaction Patient non-compliance with follow-up call or appointment Patient non-compliance with treatment regimen


Risk Management Issues (continued)

• Communication between patient/family and providers–19% Inadequate consent for surgical procedure Poor patient rapport

• Selection and management of therapy–15% Selection of surgical procedures

• Insufficient or lack of documentation–10% For informed consent Re: clinical findings Re: clinical rational


GYN Patient Injuries

• Puncture/perforation–19%• Death–9%• Foreign body–5%• Malignancy–5%• Infection–5%• Emotional trauma–5%• Laceration/tear–5%• Burn– 4%• Fistula–4%


GYN Patient Injury Severity

Injury Severity for GYN PatientsClaim Count

DEATH 32PERMANENT GRAVE 4PERMANENT MAJOR 7PERMANENT SIGNIFICANT 19PERMANENT MINOR 76TEMPORARY MAJOR 166TEMPORARY MINOR 41TEMPORARY INSIGNIFICANT 7EMOTIONAL ONLY 18 *TOTAL 370

Injury Severity Sub-category for GYN Patients

Claim Count

High 62Medium 283Low 28 *TOTAL 373


Procedures from Which the Injury Arises

Procedures Related to the Injury Claim Count

Percent of Total

ZZZ - NONE/NULL 66 18%68.4 - TOTAL ABDOMINAL HYSTERECTOMY 60 16%68.51 - LAP ASSISTED VAG HYST 28 8%54.21 - LAPAROSCOPY 24 6%68.5 - VAGINAL HYSTERECTOMY 19 5%68.59 - VAGINAL HYSTERECTOMY OTH 11 3%68.12 - HYSTEROSCOPY 10 3%65.61 - BILA SALPINGO-OOPHORECTOMY 7 2%70.50 - REPAIR CYSTOCELE/RECTOCELE 7 2%65.4 - UNILAT SALPINGO-OOPHORECTOMY 6 2%65.39 - OOPHORECTOMY UNILATERAL 6 2%68.23 - ENDOMETRIAL ABLATION 6 2%69.09 - DILATION AND CURETTAGE 6 2%59.4 - SUPRAPUBIC SLING OPERATION 6 2%68.9 - HYSTERECTOMY NOS 5 1%54.11 - EXPLORATORY LAPAROTOMY 5 1%66.62 - SALPINGECTOMY TUBAL PREGNANCY 5 1%


Admitting Diagnosis–Top 15

Admitting Diagnosis for GYN Patients with ClaimsClaim Count

Percent of Total

626.2 - EXCESSIVE/FREQ MENSTRUATION 29 8%625.3 - DYSMENORRHEA 26 7%218.9 - LEIOMYOMA OF UTERUS, UNSP 23 6%620.2 - OVARIAN CYST OTH/ 22 6%617.9 - ENDOMETRIOSIS SITE UNSP 16 4%617.0 - ENDOMETRIOSIS UTERUS 16 4%625.9 - UNSP SYMPTOM-FEMALE GENITAL 14 4%626.8 - DISORDERS OF MENSTRUATION 14 4%618.4 - UTEROVAGINAL PROLAPSE, UNSP 13 4%626.6 - METRORRHAGIA 13 4%625.6 - STRESS INCONTINENCE,FEMALE 12 3%618.0 - PROLAPSE-VAGINAL WALLS 11 3%V25.2 - STERILIZATION 9 2%611.72 - LUMP OR MASS IN BREAST 9 2%614.6 - PELVIC PERITONEAL ADHES-FEMALE 8 2%


Final Diagnosis–Top 10

Final Diagnosis for GYN Patients' ClaimsClaim Count

Percent of Total

998.2 - PUNC/LAC DURING PROCEDURE 118 32%998.89 - OTHER SPEC CCS PROCEDURE 32 9%998.4 - FB ACCIDENTALLY LEFT DURING PR 25 7%998.5 - POSTOPERATIVE INFECTION 15 4%300.0 - ANXIETY STATE (NOC) 13 4%174.8 - MALIGNANT NEOPLASM - BREAST 11 3%998.9 - UNS COMP OF PROCEDURE (NOC) 9 2%619.0 - FISTULA URO-GENITAL TRACT,FEMA 8 2%998.11 - HEMORRHAGE COMP PROCEDURE 7 2%628.9 - INFERTILITY-FEMALE-UNSP ORIGIN 5 1%


Observations

1. The most common allegation “Improper Performance of Surgery” (53% of GYN claims) is related to:• The most common RM issue, “Technical Performance”–42% • The most common injury–puncture or perforation• The most common final diagnosis–998.2 puncture/laceration

during procedure• Other surgical issues include:

• Improper management of surgical patient–identifying and responding to post-op complications

• Retained foreign body


Observations (continued)

2. Diagnosis-related allegations (15% of GYN claims) are associated with the second most common contributing factor, patient assessment issues • Failure to order diagnostic test• Failure to establish a differential diagnosis• Failure to note clinical information


Observations (continued)

3. Some claims arise from failures in communication between patient/family and providers–the fourth most common RM issue–19%• Patients seek other providers due to dissatisfaction• Inadequate consent for surgical procedure• Poor patient rapport• A review of case abstracts reveals that language barriers

are often a contributing factor to errors or to misunderstandings between physician and patient


The Doctors Company

Our Mission is to advance, protect, and reward the

practice of good medicine.

[email protected], ext. 5186

Ob Claims - Sogh 2011

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