Updated: Adds Health Ministry's reaction
The attitude of hospital staff and their failure to provide support to the parents of a 16-month old baby who died suddenly three days after receiving emergency treatment at Mater Dei “was wrong, uncaring and insensitive”, the Ombudsman has concluded.
The child died on December 27, 2009, three days after he was diagnosed with croup at Mater Dei.
The baby’s parents had expressed regret at the attitude of the hospital authorities and their refusal for a long time to give a proper account of their son’s medical condition and the reasons that led to his untimely death. The hospital staff had argued that the issue was the subject of a magisterial inquiry.
In his considerations on the death of the baby, the Ombudsman said it would have been in the interest of the health authorities themselves to set up an internal inquiry alongside the magisterial inquiry, especially when only three days before his death the child had received treatment at the Mater Dei Emergency Department.
The Health Ministry said this afternoon it was deeply saddened by the baby's death. It welcomed the Ombudsman's report and would be taking his observations very seriously.
"It is because of cases like this that Minister Joe Cassar has been advocating the introduction of a Commissioner for Administrative Investigation (Health Ombudsman) within the Ombudsman’s office who can ascertain patients’ rights within Public Health Care Services.
"Discussions to this effect have been held with the Ombudsman. Currently the Ombudsman Act is at Committee Stage in Parliament," the ministry said.
In his report, the Ombudsman said it would have also been appropriate to hold an investigation to establish the facts should civil court action be instituted for alleged negligence or for any other failure in the treatment and for which the hospital could have been held responsible.
The Ombudsman said that he shared the views of a former Chief Justice who was consulted by the health authorities regarding this case, that a magisterial inquiry was not meant to replace a departmental or other inquiry on the same issue under the Inquiries Act.
This former Chief Justice held that the Health Division should not plead that a case was sub judice and use this as a pretext to refrain from providing information to patients or their relatives.
In this case, it remained the function of the health authorities to provide support despite any ongoing judicial intervention.
The Ombudsman said he had also sought to establish whether there was in place a system that enabled citizens to verify what happened in state hospitals to patients who were close to them.
Clearly, there needed to be ways how relatives could be given explanations for their concerns on standards of patient treatment and to any complaints that might arise.
The Ombudsman said that the Health Authorities has said that action was in hand to establish a protocol with a set of standards and procedures to be used by Customer Care Officers when handling complaints related to patients in state hospital. However, the Ombudsman said, at times it was difficult to define the extent of the information that could be given to persons who presented these requests, also in view of any litigation that could possibly arise from the details that are being released.
In this case, the doctor who examined the child at the Emergency Department seemed to have made the right diagnosis The subsequent attitude of health care staff led to a situation where the parents faced an impenetrable wall in their efforts to shed light on this tragic event. The staff had been fearful of saying anything which could in their (mistaken) opinion be in breach of the Court’s orders, coupled with fears lest anything they said could be used as evidence against them in a potential civil court case, the Ombudsman noted.
“This situation was further aggravated when the Mater Dei management turned down the parents’ request for a copy of the child’s medical records," he said.
The Ombudsman insisted that fears of a possible claim for damages could not override a patient’s basic right and that neither was this right affected even if civil court action for damages is instituted.
He said that although the child’s unexpected death occurred at his parents’ home, the fact that three days earlier the child received treatment at the Emergency Department constituted enough grounds to consider this as a case which needed to be subjected to a formal internal inquiry.
Carried out in time, this inquiry would have been in the interest of all concerned, not least the parents and the health authorities themselves, even though the case was reviewed by the senior paediatrician at Mater Dei Hospital on the day of the child’s demise.
The Ombudsman was also deeply appalled that for several months the parents received no bereavement counselling at a time of deep pain caused by their child’s death and when they most needed support to cope with their ordeal. This failure had its roots in the mistaken approach in cases where a magisterial inquiry is in place although it was at least partly remedied when the health authorities agreed to discuss the circumstances surrounding this tragic event with the child’s parents.
The Ombudsman stated that although he cannot investigate the conduct of a magisterial inquiry or its outcome, on the basis of information made available to his Office, including the child’s medical records, there was nothing to substantiate the mother’s belief that her child had pneumonia when she first took him to the Emergency Department.
“In the Ombudsman’s view this belief was the result of poor communication between the parties involved in this painful experience and although he felt that a departmental inquiry should have taken place soon after the death of the child, he expressed his reservation regarding the value of an internal investigation at that late stage.”