Malpractice by a medical team at Jerusalem’s Hadassah University Hospital, Ein Karem resulted in the unnecessary death of a 7-month-old baby who suffered a heart attack after a routine operation, the Health Ministry has concluded. The baby was perfectly healthy when he arrived at Hadassah last January for a common operation to separate the bones in his skull. Three hours later, he was pronounced dead. Hadassah recently reached a settlement with the parents under which it will pay them 1.8 million shekels ($460,000).
According to a lawsuit the parents filed before reaching the settlement, the baby was diagnosed at age four months with craniosynostosis, or premature skull fusion. Doctors recommended that he undergo an operation to separate the fused parts of the skull so that his brain could grow to its normal size. The parents said they were told this was a simple operation with little risk.
After the operation was completed, the baby was moved to the intensive care unit. He was pale and had a rapid pulse of 170 beats per minute, and his pulse rate soon climbed to 228. He began panting and writhing from side to side. But despite the warning signs on the monitor and the parents’ repeated appeals to the nurses, nothing was done. Only a few hours later did a doctor finally examine him, according to the suit. But by then, it was too late.
A medical opinion attached to the suit said there was almost no blood left in the baby’s body, and the fact that he was allowed to deteriorate into this condition constituted “criminal medical negligence. Under no circumstances did this baby have to die.”
The suit also noted that the baby was put in the ICU specifically so that he could be monitored. But from that point on, it said, the doctors and nurses paid no attention to him, even when the parents begged for help. Not only did the doctors on duty never examine the baby, but they even gave medical instructions without having examined him, the suit said. The nurse also ignored all the signs of the baby’s worsening condition, including rapid pulse, pallor and low blood pressure, and the only action she took was to give him more painkillers. Nor did any of the medical staff present notice the alarming rate at which the baby was hemorrhaging through a drainage tube.
The Health Ministry’s investigation of the incident largely concurred with the claims made in the lawsuit. “Not only was no attention paid to the [baby’s] worsening clinical distress, but when the true picture finally became clear, it turned out that the baby had no open line for a blood transfusion,” the report said. As a result, the medical crew was unable to perform a transfusion before the baby’s heart stopped.
“We intend to hold consultations with the Health Ministry’s chief prosecutor to consider taking personal steps” against those responsible, the report added. It primarily blamed the senior physician who was in charge of the pediatric intensive care unit that day.
The report, whose conclusions were obtained by Haaretz, found that the series of lapses began immediately after the baby was sent to the ICU following the operation. In contrast, it found no fault with the performance of the doctors and nurses who dealt with him before and during the operation, and said he arrived at the ICU in good condition.
But once there, “The ICU team’s mental fixation with the idea that this was an easy case, and its inattention to the possibility of substantial bleeding, led to a series of lapses that ended in tragedy,” the report said.
Inter alia, it continued, the nurses weren’t ordered to keep the doctors informed of the level of bleeding; neither the resident nor the senior physician monitored that information themselves; the doctors told the nurses to continue giving the baby painkillers even when his pulse hit 230; and communication between nurses and doctors was very poor.
The report concluded that the baby was initially in compensated shock, also known as Stage 1 shock. Had his condition been diagnosed in time, it wrote, the medical crew could have taken action that might have prevented his death. But nobody diagnosed his condition “despite the clinical symptoms, which included tachycardia, pallor and unrest.”
The report was particularly critical of the senior physician on duty, Prof. Philip Toltzis, saying the fact “that he didn’t bother to examine the patient even when his pulse rose above 200, but continued his other activities, can have no justification.” It added that since Toltzis was present in the ICU throughout the incident, he bears the lion’s share of responsibility for the baby’s death.
However, Toltzis never appeared before the ministry’s investigative committee, because he left the country.
The committee’s members included Dr. Josef Ben-Ari, head of the pediatric ICU at Meir Hospital in Kfar Sava, and Dr. Avi Cohen, head of the pediatric neurology unit at Soroka Medical Center in Be’er Sheva.
In light of the findings, Hadassah has changed its procedures for monitoring children in the ICU after operations of this sort, the hospital said in a statement, where they also extended deep condolences to the family.
The Health Ministry said the report was recently transferred to its disciplinary unit, which will examine the findings and decide whether to take further steps against anyone involved.
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