State probe finds boy who died from fall misdiagnosed with dehydration
Health Ministry ombudsman, Dr. Chaim Hershko, ruled that the boy's death was a combination of a misdiagnosis of Maor's condition and the failure to follow procedure in cases involving head injuries.
Serious flaws in medical care were found by a Health Ministry probe of alleged malpractice at Kfar Sava's Meir Hospital in treating an 8-year-old injured in a soccer game. Second-grader Maor Shriki died from the head injuries he suffered in a fall in a June 2006 soccer game during gym at his Ra'anana elementary school. Disciplinary proceedings have been filed against Dr. Pinhas Feinmesser, the head of the pediatric emergency department at Meir.
During the soccer game, when the school nurse arrived, the boy was pale and weak but conscious. He was taken to Meir Hospital, where the pediatric emergency room staff erroneously found that he was suffering from dehydration. Consequently, the staff did not perform a CT scan, which could have shown that Maor was suffering from internal bleeding in the brain. He was transferred to the hospital's pediatric department, where nurses reported that he was conscious and engaging in play.
Overnight, however, his father witnessed him vomiting and by morning, Maor had lost consciousness. A CT scan was done and revealed the brain bleeding. The boy was rushed to Schneider Children's Medical Center in Petah Tikva, where surgery opened his skull to drain the blood. His condition, however, continued to deteriorate; a month later, he was declared brain dead.
An internal investigation by the Clalit health maintenance organization, which owns Meir Hospital, cleared Meir's staff of wrongdoing. The Health Ministry probe, however, found serious shortcomings in the care Maor got in Kfar Sava, particularly the diagnosis of dehydration.
The Health Ministry panel, which was headed by Dr. Zeev Feldman, the head of the pediatric neurology department at Sheba Medical Center, Tel Hashomer, also noted that because of the misdiagnosis, medical imaging tests were not performed initially, and Maor was not monitored for signs of a brain injury, as required.
The ministry panel said that during the night after the boy's hospitalization at Meir Hospital, a nurse found Maor had an abnormal pulse and elevated blood pressure but did not alert a doctor. Following the panel's findings, the Health Ministry ombudsman, Dr. Chaim Hershko, ruled that the boy's death was a combination of a misdiagnosis of Maor's condition and the failure to follow procedure in cases involving head injuries. Had the injury received proper attention, there was a possibility the patient's death could have been avoided, Hershko said.
In March of last year, Hershko recommended that disciplinary proceedings be brought against Feinmesser. "Among the three doctors involved in treatment, Feinmesser was responsible as the senior physician for the erroneous assessment, whereas the two junior doctors who treated the boy subsequently in the department were following that assessment," Hershko wrote.
Feldman was joined in the probe by Dr. Ido Yatziv, head of pediatric intensive care at Hadassah University Medical Center, Ein Karem, and Sima Levy-Movshovitz, a lawyer with the ministry.
Meir Hospital said in response: "We share the family's grief in this tragic incident. The report by the committee convened by Clalit and the Health Ministry report are similar in most of their conclusions. The two reports show that the hospital staff acted as would be expected. Nonetheless, both reports raised matters that needed to be addressed. Prof. Hershko's request that a complaint be filed against Dr. Feinmesser is not a recommendation on the part of a committee member, and we welcome [Feinmesser's] being given an opportunity to present his position on the sequence of events." The Clalit HMO said it rejected any suggestion calling into question the work of the internal investigation.
In the report issued by the Clalit HMO in its internal investigation of Maor Shriki's treatment at Meir Hospital, the care the boy received was termed "within acceptable limits under the circumstances of the case." That probe, which was headed by Dr. Nathan Ish-Shalom of the Carmel Medical Center in Haifa, found that Maor's case was unusual in that his condition deteriorated more than 12 hours after he received the blow to his head. "During those 12 hours, there was no clinical sign raising suspicions of bleeding within his skull," the internal committee stated.
Lawyers for Maor Shriki's family, Doron Caspi and Shira Pridan, took the members of the internal Clalit probe to task for allegedly failing to interview the four nurses on duty during the evening and night following Maor's admission to Meir Hospital.
As a result of Maor Shriki's case, the Health Ministry committee recommended that ministry procedure for the treatment of head injuries be revised, and that the recommendations also be provided to nursing staff and to children's parents regarding symptoms for which they should be the alert.
In an unrelated case that recently came to light, an internal investigation was launched into the death of a 49-year old woman, Orna Katan, at Clalit-affiliated Beilinson Hospital in Petah Tikva, following surgery for the removal of a growth from her nose. That internal probe found no wrongdoing on the part of hospital staff, but a Health Ministry found that Katan's death could have been avoided.