Three senior doctors at Hadassah University Hospital were found guilty recently of severe medical malpractice in the 2003 death of a 13-year-old boy. The teen was misdiagnosed with appendicitis despite severe diabetes having caused swelling of the brain. A Health Ministry disciplinary body found the Hadassah Ein Kerem doctors did not properly treat the results of urine and blood tests that indicated his collapse was the result of diabetes, and that the doctors were "overeager" to operate to locate the infected appendix, ignoring medical information and the results of lab tests.

The committee of the disciplinary court heard a complaint against three doctors filed by Dr Boaz Lev, deputy director general of the Health Ministry, following the ministry's investigation into the teen's death. Pediatric surgeon Dr. Boris Orkin has since moved to Jerusalem's Shaare Zedek Hospital, while surgeon Miklush Behla and anesthesiologist Luminza Eid are still with Hadassah Ein Kerem.

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During the hearing, prosecutor Jonathan Berg said all the witness testimony indicated none of the doctors worked "as is to be expected of a reasonable doctor. All three exceeded accepted medical norms in ignoring results of lab tests and in failing to wait for the results of tests that should have supported a diagnosis."

A senior Health Ministry legal official told Haaretz that sentencing, which could range from a reprimand to a warning prior to losing licenses to practice medicine, will be determined by retired Judge Vardi Zeiler.

On the evening of August 9, 2003, Eliezer Luverbaum was taken to a medical clinic suffering from severe stomach pains and excessive urination, which had begun during the Tisha B'Av fast two days earlier. The examining doctor raised the suspicion of appendicitis, but lab tests indicated high sugar levels and acidic urine. The youth was transferred to Hadassah Ein Kerem's emergency room and examined by intern Dr. Anatoly Lieberman and the surgeon on-call, Dr. Miklush Behla. Both believed the teen was suffering acute appendicitis and ordered blood and urine samples tested.

Pediatric surgeon Dr. Boris Orkin was called to the operating room and concurred with the appendicitis diagnosis without reviewing the patient's medical file. Dr. Luminza Eid put the patient under anesthesia before the arrival of lab results indicated serious diabetes and acid in the blood. Nonetheless, Orkin and Behla decided to continue the surgery, which revealed no infection of the appendix. The teen was transferred to intensive care unit in a coma and suffering severe swelling of the brain. He died the next day.

The surgeons' defense attorney told the court that the emergency room and the doctors were under intense pressure at the time of the event and that "diabetes can show signs similar to appendicitis." He called Dr. Behla's actions "negligence but not severe negligence" and said "Orkin's actions cannot be called negligent."

The attorney of anesthesiologist Dr. Eid said she should be acquitted because the surgeons "had failed to diagnose the patient's diabetes", saying she based her decision to begin anesthetizing the patient on the urgency of an appendicitis operation. The defense attorney also noted Eid was the first to make the correct diagnosis when lab results did arrive.

The committee, however, agreed with the Health Ministry and called the behavior of all three doctors "severe medical malpractice." It also found a series of missed opportunities due to the doctors' failure to communicate with each other.

The committee found the series began when Behla and intern Lieberman didn't share vital information with the on-call surgeon and the anesthesiologist. Committee members also faulted Orkin for failing to examine the patient's chart, "which caused him to err in the weight and significance he attached to clinical symptoms. In addition, he failed to wait for results of tests done in the emergency room before the surgery."

The committee also faulted Eid who "should have known that even an appendicitis diagnosis allows the medical team to wait for the results of the tests." The committee ruled that "as an anesthesiologist, she could have convinced her colleagues to wait for the results and cooled their eagerness to operate."

Hadassah stated the hospital had "drawn the necessary conclusions and will take operative measures." Dr. Orkin expressed his condolences to the family and said he respects the disciplinary court's finding.