A woman's death in 2008 from a severe infection following a hysterectomy that may have been unnecessary was due to the negligence and complacence of an Assouta Medical Center gynecologist and the hospital's management, a Health Ministry panel said on Monday.
In its report, the committee said there was evidence that the surgery performed on Inesia Diskin, 46, was unnecessary, and that the surgeon, Dr. Eylon Lachman, failed to detect an intestinal perforation until days later, when she developed a severe infection. Diskin died about a month after the operation.
The committee also criticized the administration of Assouta, which is a private hospital, and its then-deputy director Dr. Orna Ophir, for not approving Diskin's transfer to a general hospital, though her family had requested it. The committee recommended that the Health Ministry issue clear guidelines regarding the transfer of patients suffering complications from private hospitals to general hospitals.
Diskin, an engineer, who is described in the report as generally healthy, was operated on at Assouta in September 2008. According to the family, Lachman had said there were cancerous cells in her body requiring an immediate hysterectomy, but the medical records show that the operation was ordered because of fibroids in the uterus, which the panel said "present no reason for a hysterectomy."
A day after the operation, when she was still in Assouta's surgical ward, she began complaining of severe pain. Though Lachman visited her several times a day, the committee said that for three days he did not detect evidence that she may have suffered a perforated intestine.
Because of the delayed diagnosis, Diskin developed a serious infection, but it was only the next day that she was re-operated on, after which she was sent to intensive care and put on a respirator.
Over the ensuing four days, she seemed to be improving, but then her lungs started to fail and various infections continued to develop. Her condition deteriorated until she died a few weeks later.
The ministry panel found several faults in Diskin's treatment, including a lack of documentation of the gynecological exam that was done before the hysterectomy; that surgery was performed "without proper clinical data and apparently without need," and a delay in detecting the post-surgical complication.
"A senior surgeon must be aware of all the possible complications that could arise from the operations he performs; Lachman's moral eclipse led to dangerous complacency that significantly contributed to the delay in the diagnosis," the panel said.
The committee also criticized the duty physician at Assouta, "who was party to the clinical complacency."
The ministry committee, headed by Prof. Zvi Gimon, a surgeon at Hadassah University Hospital at Ein Kerem, has passed the findings to the Health Ministry ombudsman for a decision on disciplinary action against the physicians.
The family has filed a malpractice suit in Jerusalem District Court against those involved.
Lachman said he "totally rejects the committee's findings, which have no medical support. We have the opinions of world-renowned experts that completely contradict what the report says. What is especially strange is that the committee ignored the fact that surgery was approved by an external consultant at the Meuhedet health fund who is a senior gynecologist at a government hospital."
Assouta said, "Inesia's tragic death was an exceptional occurence that happened in 2008 in our old location. This event does not reflect the reality in our new hospital, which has one of the top intensive care units in Israel and a range of expert consultants."
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