A series of oversights led to the death in 2008 of a 53-year-old woman a few hours after undergoing surgery to open blocked arteries in her leg, the Health Ministry has ruled. A report by the committee investigating the incident was released yesterday. No decision has been taken regarding disciplinary action at this stage.
The patient, a resident of Rishon Letzion, was admitted to Assuta Hospital in Tel Aviv in Feburary 2008, complaining of severe pain in her right foot. She had a history of diabetes and heart disease and was overweight.
A surgical team led by the chief of the hospital's vascular surgery department, Prof. Edward Shifrin, performed catheterization on the leg. According to the committee's report, after expanding two arteries using a balloon inserted into a sleeve, the surgeons were unable to deflate the balloon in order to remove it. One of the surgeons then pulled the balloon out, still inflated, along with the sleeve, causing a blood vessel to rupture.
After the surgeons tried to stop the bleeding using manual pressure, successfully, according to the doctors, the patient was taken to the recovery room. About 30 minutes later she began complainin of pains in her pelvis. A pressure bandage was applied to stop the hemorrhaging, with the patient cooperating and turning around to allow the bandage to be put in place.
About 10 minutes later the patient's condition deteriorated. The patient was taken to intensive care.
According to the report, some three hours and forty minutes after the catheterization was complete, the patient suffered a systemic collapse and she required resusication. Prof. Shifrin arrived to the unit only ten minutes later, and told the committee it was only then he was told of the difficulties in the morning's operation.
The patient died 20 minutes after he arrived.
The health ministry report, authored by Dr. Anthony Verstandig, a radiologist at Shaare Zedek Medical Center in Jerusalem, listed a number of oversights and flaws in the procedure, including the patient being asked to sign an agreement form despite have poor eyesight and being unable to read, insufficient caution in removing the sleeve with the balloon and the lack of discussion among the many physicians who treated the woman in the different phases of her deterioration.
"Every physician tried to place the blame at the door of one of his colleagues," the report said, before sharply criticizing Shifrin. "The surgeon and the catheterization team at Assuta were not involved in treating the patient, and even after they learned her condition was deteriorating, didn't take responsibility for treating the patient as they should have," the report said.
"The fact that the operation team and the surgeon ... didn't see themselves as responsible for coordinating the treatment of a post-surgical complication negated any possibility of proper treatment. The entire team fully realized the patient was suffering from an internal hemorrhage, but they were waiting for Dr. Shifrin's decision, while he was busy in other operations."
The committee said Shifrin had failed to manage the treatment of the patient. "The root of the problem is the absence of a senior physician who would take responsibility for leading the treatment," the report said.
Asuta Hospital said in a statement that the incident was "regrettable and rare."
"It was immediately reported by the hospital to the health ministry, and inquiries were made with the physician," the hospital said. "Proper work procedures were stressed to the physician. The hospital extends its condolences to the family."
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