Health Ministry: Kidney Patient Died Because of Faulty Treatment

Investigation committee determined that mainly because of understaffing and the large number of patients, care in the dialysis room had been faulty.

A 74-year-old kidney patient who died three years ago at Haifa's Carmel Medical Center died because of faulty treatment, the Health Ministry said after conducting an investigation.

Miriam Eliyahu, a resident of Tirat Hacarmel, was a dialysis patient with an irregular heartbeat. She was hooked up to an external pacemaker in the emergency room, but at some point after she was sent to the nephrology ward, the pacemaker was disconnected.

The committee also recommended changes in the way pacemakers are used in Israeli hospitals.

On March 15, 2007, Eliyahu felt ill after dialysis at a clinic near her home. The staff there saw that her arm was infected and sent her to Carmel Medical Center.

An hour after Eliyahu's arrival in the emergency room she was sent to the nephrology ward for dialysis. The doctor on call at home, Dr. Jerome Marcuson, told the committee that two hours after the start of treatment she was still connected to the pacemaker. But 90 minutes later the family reported to the duty doctor at the ward, Dr. Avraham Shlibovsky, that the pacemaker had been taken away.

Shlibovsky told the committee that when he called the emergency room, he was told that the pacemaker belonged there and another patient needed it. He said removing it had not been cleared with him first.

However, others told the committee that Eliyahu had already been disconnected from the pacemaker when she entered the nephrology ward. "None of those interviewed knew for certain when the pacemaker was taken away and by whom," the committee said.

When Shlibovsky saw that Eliyahu was suffering from an infection, he removed the shunt, at which point Eliyahu lost consciousness. Shlibovsky said he called in the resuscitation team, but reports differ on how the doctors on call were summoned.

Ward personnel testified that the ward was overcrowded and disorderly that day. They said the head nurse had fallen ill at the beginning of the shift and herself had to be hospitalized.

The committee determined that Marcuson, whose testimony it called "evasive and even surprising," did not come to the ward despite the emergency. Instead, two senior cardiologists were called to the hospital to try to revive Eliyahu. She died shortly after an attempt to reconnect her to a pacemaker.

The committee determined that mainly because of understaffing and the large number of patients, care in the dialysis room had been faulty. It added that disconnecting Eliyahu from the pacemaker ran contrary to hospital procedure and did not conform to reasonable standards of care.

The committee also criticized senior physicians at Carmel for not discussing the problems at the ward.

The committee, which was appointed after the family lodged a complaint with the Health Ministry in September 2007, has not yet decided whether to take disciplinary action.

"When older adults are hospitalized, their children have to be there all the time to monitor their medication and hookup to equipment," one of Eliyahu's three children said. "If we had left her, we wouldn't have even known what happened."

Carmel Medical Center said in a statement it was taking the committee's recommendations to heart and had already instituted changes.

The Health Ministry said it had conveyed its conclusions to its commissioner of public complaints.