Five Fatal Failures Before Boy's Death

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02.01.2019.

Zagreb, 011018.
Potpisivanje Ugovora o javnoj nabavi robotskog kirurskog sustava u Ministarstvu zdravstva. Ugovor je potpisao ministar zdravstva Milan Kujundzic. To je prvi robotski kirurski sustav u Hrvatskoj koji ce biti smjesten u Klinici za urologiju Klinickog bolnickog centra Zagreb. Na fotografiji: Milan Kujundzic.
Foto: Ranko Suvar / CROPIX
Ranko Šuvar / CROPIX

Milan Kujundžić

The nine-year-old died at the Split KBC on 11 December, where he was transported by helicopter, too late for anything to be done.

On Thursday, after nine days, the Ministry of Health finally announced the findings of the Commission that had investigated the reasons for the death of G.B., a boy of 9, in Metković two weeks ago. Despite all efforts of his parents, who took him to the local ER and to pediatricians several times, worried about his poor health condition, the boy died. The conclusion of the Commission is that omissions were made in the handling of the case, and that nether the boy's ailment nor the severity of his condition were recognized in time.

"Summing up the testimonies of all healthcare workers who took part in the medical care of G.B., a minor, and analyzing the accompanying medical records and autopsy findings, the commission concludes that neither the boy's ailment nor the gravity of his clinical picture were recognized" — say members of the Commission in the report. Shortcomings have also been noted in preparation for the boy's medical transport.

Key details

"The Commission concludes that, on 10 December, 2018, following the recognition of a clinical syndrome and a threat to the patient's life, omissions were made during the initial treatment, volume resuscitation, oxygen therapy and the preparations of the patient for transport to the Split Clinical Hospital Center [KBC]" — says the release issued by the Ministry of Health. It also notes that the entire documentation about the case, as well as the conclusions of the expert commission, have been forwarded to the Office of the State Attorney (DORH) for further action.

A reminder: the nine-year-old died on 11 December at the Split's KBC, where he was taken by helicopter from Metković. His condition upon arrival was so grave that the hospital medical team failed to save his life. It was only in Split that the boy was finally diagnosed with the so-called swine flu aggravated by streptococcal complications and eventually a severe sepsis that affected all vital organs. Unfortunately, the Commission finding also confirmed a series of failures during the treatment that preceded the child patient's arrival to Split.

First examination

As early as the beginning of December, when the flu had just started, the boy's father brought him to the Metković Health Center with severe cough. He was prescribed antibiotics. As his condition continued to deteriorate, the boy ended up in the local ER, but the doctor's conclusion there was that there was no reason to panic. The father was advised to consult a pediatrician in the morning.

The boy had little luck with that because his regular pediatrician was working a different shift, so his father sought help from another. The other pediatrician refused to admit him, claiming "a great number of other patients". He was finally received by the third, Dr. Ksenija Kaleb. She immediately realized that the boy's condition was alarming and sought urgent helicopter transport to Split.

According to her account, the child had difficulty breathing and had symptoms of hypothermia. She suspected sepsis. The stethoscope examination showed one lung as inactive; also his throat was almost closed. Transport to KBC Split was organized an hour and a half later. In Split, the doctors could not do anything about it, all their efforts notwithstanding. The boy died — despite the fact that he had been seen by four different physicians in the previous 24 hours.

It is particularly difficult to accept that during all those visits not even a blood test was done, or indeed any other kind of laboratory test. The justification offered for that fact is that the Metković laboratory is closed over the weekend. This was also confirmed by the director of the Metković Health Center, Dr. Mihovil Štimac, but he told us that the physicians should nevertheless have recognized the emergency and called the laboratory staff in to perform tests.

The boy was ill for nearly two weeks, yet no one had ever tried to confirm or eliminate the flu as the cause of his illness. It turned out that the streptococcal infection, an occasional complications with the flu, particularly in sensitive children, chronic patients and the elderly, was the fatal factor.

Mistakes made in transport

Luka Lulić, the director of the Emergency Medical Assistance of the Dubrovnik-Neretva County, did not want to comment on the Commission's findings on Thursday, saying he had not receive the Ministry report. However, one of the conclusions in the document concerns the failure to prepare the small patient for the transport to Split properly. Among other things there were apparently omissions in the application of oxygen during transport. After Dr. Kaleb concluded that hospitalization was necessary, the patient was taken over by the emergency medical service, which performs such preparations. It is not clear from the release what exactly went wrong then, and it will likely be seen only from the detailed report of the Commission, which is not available to the public at the moment.

It seems clear, however, that the transport to KBC Split was more or less damage containment, after ten days of mistakes and omissions in treatment in Metković, starting with the failure to diagnose the boy's ailment. As Dr. Marijan Saraga of the Split KBC confirms, when G. B. arrived to Split it had already been too late. He says the boy was admitted to the intensive care unit with sepsis. There was a multi-organ failure resulting in death. It was only in Split that the physicians found the boy had a flu and a streptococcal infection. The original cause of the problem, the Commission experts say, was the poorly performed diagnostic procedure in Metković.