Health Ministry files complaint 5 years after girl, 3, died

Public complaints commissioner recommends filing official complaint against 2 doctors 60 months after tonsillectomy death.

By JUDY SIEGEL-ITZKOVICH
doctors operating room 311 (photo credit: HBL)
doctors operating room 311
(photo credit: HBL)
The Health Ministry’s public complaints commissioner, Prof. Chaim Hershko, on Monday recommended the filing of an official complaint against two doctors five years after a three-year-old girl died of a hemorrhage following the removal of her tonsils.
The Jerusalem hospital where the surgery was performed, Misgav Ladach, is no longer a general hospital owned by a voluntary organization, but was purchased by Kupat Holim Meuhedet and turned into an outpatient and geriatric center. The other doctor worked at Hadassah University Medical Center in Ein Kerem.
The ministry did not explain why it took 60 months to release its recommendations.
According to the ministry’s new statement, the girl was the last patient that day in late November 2005. Soon after discharge, her parents returned to Misgav Ladach saying that she had vomited blood. The anesthesiologist brought her back to the surgical theater to look at her throat. Without calling an ear, nose and throat (ENT) expert, he decided to discharge her.
Five days later, she coughed up a large amount of blood and was taken to Hadassah University Medical Center on Mount Scopus, where she lost consciousness in the lobby. By the time she reached the emergency room, she had no pulse and was not breathing. She was rushed to the surgical theater for resuscitation and suturing and then was transferred by ambulance to the pediatric intensive care unit at Hadassah University Medical Center in Ein Kerem while unconscious and attached to a respirator.
A pediatrics resident who was on duty in the unit phoned the on-call specialist at his home, saying he was worried that the packing to prevent more bleeding had been left in her throat. He called the ear, nose and throat specialist, who, during a 20-minute conversation, advised him to remove the packing.
At 6 p.m., her condition declined with a significant rise in fever and irregular heartbeats. The resident was told to give her an infusion. At 9:30 p.m. – six hours after admission – the specialist arrived. Despite resuscitation, the girl died at 1 a.m. the next day.
The ministry committee that investigated the case said the Misgav Ladach anesthesiologist should not have discharged the girl without calling an ENT, a decision that violated medical practice – as in similar cases, patients are left in the hospital for supervision for 24 hours. Another failure, according to the committee, was at Hadassah’s intensive care unit, which did not “give her proper treatment” and whose specialist did not immediately come to the hospital to attend to her. He and the Misgav Ladach anesthesiologist will be summoned to a hearing, the ministry said.
The Hadassah spokeswoman said the hospital received the ministry’s conclusions “only a few days ago, and we have objections to some of the findings.” The doctor, she said, is an excellent pediatrician and works now at Kaplan Medical Center in Rehovot but comes to Hadassah once a month for duty work.