A Fatal Mistake
By Abdul-Wahab Eliwa and Mohammad Abdul-Salam
Cairo, Egypt (AlHayat), Jan, 2016 – The door of the operating room in a government hospital in Egypt remained shut for more than four hours, during which Khilaf Gamal, head of the family, underwent a cholecystectomy on January 12, 2015.
The surgeon’s scalpel did not only remove the gallbladder, but also cut the bile ducts, causing the formation of blood clots in Gamal’s body. This affected the functions of his liver which developed into cirrhosis, according to a medical report issued on 3 February by Qasr Al-Aini’s Medical College Hospital at Cairo University.
Gamal was admitted to this hospital after the other state-run hospital where he underwent his first surgery, refused to admit him again – either because the sonography equipment or because the doctor who operated on him was unavailable, according to the victim’s father Gamal Abdul-Rahim.
After nearly 52 days at the ICU in Qasr al-Aini, Gamal died. In a letter to his family, he asked them not to let his “death be in vain, for the sake of my children. The doctor must be held accountable.”
Gamal’s case is but one example of medical errors that occur every day in the operating theaters of both private and government hospitals. While many patients are unaware of their legal rights some have filed complaints to entities such as the Public Prosecution, the Doctors Syndicate, and the Ministry of Health. Each entity has its own protocols and regulations governing how they investigate complaints. They do not coordinate with other relevant bodies. As a result, perpetrators have often escaped punishment, in the absence of legislation that ensures accountability and protects the rights of patients.
According to the latest statistics of the Ministry of Health, there were 1,866,529 surgical procedures performed in 2014.
Complicating matters further is a shortage of provisions in the Expert Law that regulates the workflow inside the Forensic Medicine Department, compelling doctors or morgues to submit reports within a specified period. Currently, all the Prosecution can do is send an urgent memo, which means there is no way to obtain conclusive evidence confirming or denying medical error.
Gamal Abdul-Rahim, his father, said he filed a complaint No. 880/2015 at the Giza Police Station asking for those responsible for the neglect to be held to account. The family agreed to have the body exhumed for an autopsy, but several months after Gamal’s death in mid-March last year, this is yet to happen.
The reason the bodies of the victims are yet to be examined, said Dr. Kamal al-Saadani, former head of autopsies at the Forensic Medicine Department, is the limited number of qualified forensic doctors who conduct autopsies. He said only 15 doctors work at the morgue covering Greater Cairo, out of 115 forensic doctors in the department who otherwise collect samples and deal alone with 190,000 cases nationwide each year. The rest, he said, work in the chemical labs and other facilities in the department’s divisions.
Ayman Fouda, former chief forensic doctor, said there is only one central lab in all of Egypt, in Cairo. Often, the lab has to process 100 corpses per day, which means every doctor has to conduct 494 autopsies a year, nine times the global average.
Fouda said the corpses that undergo autopsy at the Zeinhom morgue in Cairo governorate number around 4380 a year and up to 32,000 corpses arrive annually from the rest of the governorates to the morgue. It is the only morgue operated by the Forensic Medicine Department nationwide.
Dr. Alaa Ghannam, in charge of the health sector under the Egyptian Initiative for Personal Rights said the Expert law of 1952 does not include an article forcing doctors at the morgue to issue a report within a set period of time. If the report is late, the Prosecution can only send a letter asking officials at the morgue to speed up the process.
Research prepared by a team from the Forensic Medicine Department and the Clinical Toxicology Department at the University of Cairo and the University of Bani Suef covering the period 2009-2011, showed 4095 cases involving suspected medical errors resulting in deaths in Cairo and Giza governorates – according to cases being considered by courts and Public Prosecution offices.
According to the study published in the Egyptian Journal of Forensic Sciences supervised by the Egyptian Autopsy Institution on August 27, 2014, judges have examined 2595 complaints in the Cairo governorate alone> But only 177 bodies underwent autopsy to verify the cause of death or 6.8 percent of the cases. The number of similar cases in the Giza governorate was 1500, but autopsies were carried out on 66 bodies only or 4.4 percent. In other words, the number of bodies that underwent autopsies in Cairo and Giza was 243 out of 4095 or 5.9 percent.
According to statistics by the Ministry of Health, the number of complaints involving allegations of medical errors last year was 2094: The Public Prosecution received 594 complaints, the Ethics Commission at the Doctors’ Syndicate dealt with 600 complaints; and the Free Treatment Department at the Ministry of Health handled 900 complaints.
But this number is only the tip of the iceberg, according to Dr. Hossam Abdul-Ghaffar, spokesman for the Ministry of Health. He said: “We can say that there are 8,000 cases where no complaints were made for different reasons.”
However, he insisted that the proportion of medical errors in Egypt does not exceed 6 percent of operations conducted annually, quoting a report by the WHO issued early this year entitled “Medical Malpractice and Patient Safety in the Eastern Mediterranean Region”.
The proportion is small, according to Abdul-Ghaffar, compared to other countries like the US where 4 out of 100 patients that undergo surgery suffer from complications resulting from medical errors, as he said.
On the other hand, Dr. Alaa Ghannam, expert on medical legislation and reform, said the US has accurate medical databases and constantly updated legislation regulating the healthcare sector, unlike the chaos prevailing in Egypt. In Egypt, he continued, there is no comprehensive data on medical errors or the victims of medical neglect, but only data on complaints filed by victims which he said does not offer much by way of information on the total number of victims of malpractice.
Shaaban al-Shami, Assistant Minister of Justice for Forensic Medicine, confirmed the lack of accurate data. “There is no official figure we can rely on to determine victims of medical errors.” Shami pointed out that he requested the Public Prosecution to survey all cases involving medical errors to produce a database that can act as a reference for complaints filed by victims without getting their rights.
In the trash bin
The trash bin is often the place where complaints against medical errors end up, according to a study by Dr. Sonia Azab, researcher in the Department of Toxicology and Forensic Medicine at Ain Shams University’s Faculty of Medicine.
The study published in 2013 examined 92 cases that had been investigated out of 1379 cases received by the heath authorities in 2008 and 2009. These cases ended with 35 doctors being acquitted and 28 being suspended, while 24 doctors were fined no more than 1000 L.E. ($125) in accordance with the bylaws of the Doctors Syndicate. Four doctors were given warnings while one had his license revoked. The researcher concluded that nearly 93.4 percent of complains end up being discarded.
Dr. Ayman Fouda, former chief forensic doctor and vice president of the Egyptian Society for Medical Forensic Sciences, said there are 13 laws and 75 ministerial decrees regulating the medical profession. He said this multiplicity perpetuates chaos in the health sector in Egypt, calling for a unified law to be passed.
The delay in forensic reports on medical errors is not the only problem. Sometimes, conflicting reports are issued on the same case, such as that of writer Nadine Nabil Abdul-Khaliq (Nadine Shams) who died in March following a surgery to remove a tumor in her ovaries.
According to the report by the administration of this famous hospital, Nadine died of a clot in the pulmonary vein, an account which was endorsed by the forensic doctor’s report that explained that the death was not the result of a medical error. However, her husband Dr. Nabil al-Qot, psychiatric counsellor, filed a complaint with the Ministry of Health.
The ministry assigned Dr. Mohammad al-Qulaawi, professor of oncology, to prepare a report on the case, according to a copy obtained by the reporters. The report in question confirmed the death was the result of an error during the surgery which caused a puncture in the intestine. This was closed without detecting the medical error, causing a gradual deterioration in her health, followed by coma and death.
After a year-and-a-half, the case is still open at the Public Prosecution pending a new report to be released by a tripartite forensic committee.
Dr. Kamal al-Saadani, former head of autopsies at the Forensic Medicine Department, said the conflict in reports is natural because reports rely on the point of view adopted by the forensic doctor in accordance to evidence and data. He said when there is new evidence, a new report with different contents could emerge. He also said the law allows the aggrieved to complain and demand the formation of a tripartite committee comprising more experienced members to reexamine the case.
Hiba al-Ayouti is another victim who died from complications following a color X-ray image procedure at a private hospital in Cairo in May last year. The Doctors Syndicate said there was no evidence of a medical error leading to the death, in contradiction of the forensic report that the Public Prosecution and the Dar al-Salam court relied on in issuing its verdict in the case (16761/2014) misdemeanor, sentencing the doctor to 5 years in prison, and two nurses to two years and one year respectively for manslaughter.
Hiba’s condition deteriorated when she was mistakenly injected with formalin (antiseptic) ahead of the process. This was discovered by the radiology technician who told the doctor. The doctor, fearing legal repercussions, asked the patient to leave and the receptionist to remove her information from the records, according to the victim’s family.
The patient died 29 days later after moving between three hospitals in which she underwent three critical surgeries. A medical report released by the Park Clinic hospital of Berlin, Germany, where she went for a last-ditch attempt to save her life, blamed the radiologist for failing to help her. The report said the physician could have moved her to the operating theatre and carried out a dialysis to remove the toxic substance from her body.
The Cairo Medical Association formed a medical commission, which said in its final report there was no evidence of formalin as the forensic doctor’s report had stated, claiming there were several possible causes for the death.
The court verdict relied on Article 238 replaced by Law No. 120 of 1962. The judge considered the patient’s death the result of the perpetrators (the radiologist and two nurses) violating the principles of their profession and failing their duty at the time of the incident, by not helping the victim or requesting help for the victim.
Ayman Rabeh, head of the Egyptian Society for Medical Negligence, said the verdict was unique and “the harshest in the history of similar cases”. But he said this was because of the failure to provide medical help to the patient despite knowledge of the medical error and not because of the error itself, which is not punishable by more than six months in accordance to the first paragraph of the same article.
Rabeh said that despite the verdict, the Public Prosecution referred five other officials at the private hospital for investigations in the same incident, recorded under No. 8090/2014. Despite that, the Prosecution continues to maintain the innocence of the doctor while the hospital continues to operate.
In addition to the conflict in medical reports, victims of medical errors suffer from delays in the procedures. This prompted the individuals who filed 19 cases pending before the authorities to hold a protest on June 3, outside the Ministry of Health, following huge delays in the issuance of forensic reports.
Mahmoud Fouad, lawyer and director of the Egyptian Center for Medical Rights which is handling all the cases, said his clients underwent medical surgery for treatment of excessive obesity.
He said that one of the victims, Nagwa Hassan, a gynecologist at the Shubra General Hospital, now suffers from permanent disability following a gastric bypass surgery that left her stomach severely damaged. This caused her to develop chronic disease that requires continuous treatment including putting on excessive weight after the surgery that was intended to treat her obesity in the first place. On the same day, her sister Amira who underwent the same surgery died from complications after blood stopped circulating to her brain.
Dr. Essam Abdul-Galil, who is accused of medical errors according to complaints by the victims, declined to comment. He said: “It is the right of every patient to file complaints, and the Doctors Syndicate commission decides whether an error had occurred or not.”
The authors visited the hospital, which remains operational despite assurances by Ministry of Health Spokesman Dr. Abdul-Ghaffar that a decision was issued to close it down.
The new spokesman for the ministry Dr. Khaled Mugahid did not deny that such a decision had been issued. He said the decision was made based on investigations conducted by his ministry into the accusations against the doctor there. When we told him we visited the hospital and found it to be operational, he said the whole issue is now in the hands of the Public Prosecution and the Ethics Committee of the Doctors Syndicate.
The problem, said Saad al-Shazly, head of the Free Treatment Authority in Giza, a division of the Ministry of health responsible for monitoring private medical institutions, is not the closure or not of clinics in violation but ambiguous legislation that allows decisions to be circumvented. Most clinics, according to this official, exploit legal loopholes in laws related to violating closure decisions and breaking seals.
Article 147 of the Penal Code punishes guards of paying a fine of 500 L.E. only if a seal imposed by a government authority or court is broken.
Private hospitals have taken advantage of this leniency and loopholes to dodge closure decisions, most recent of which is decision No., 127 of 2015 (July 14). A previous closure decision was issued on 8 October 2013, after two people died.
In Giza alone, up to 10 closure decisions are issued each month, according to data from the Free Treatment Authority of the Health Directorate in the governorate. In the past six months, 53 health facilities were closed. In August, 21 closure decisions were issued following routine inspections, but only a tiny proportion was the result of complaints.
Lack of coordination
The measures taken by the Doctors Syndicate and the Ministry of Health are poorly coordinated. The first has since 2009 sought to get a law on medical responsibility passed. The law was approved in parliament in 2010, but has yet to be issued, according to former head of the Doctors Syndicate Dr. Hamdi al-Sayed who submitted the law with the chairman of the health committee in parliament at the time.
Political unrest since the January 25 revolution has prevented the law from being issued, said Dr. Sayed.
Determining responsibility for medical errors requires a specialized committee along the lines of what happens in Western nations and Arab countries like the UAE, Sayed explained. He said permanent technical commissions should be formed at the Ministry of Justice comprising representatives from the Ministry of Health and medical professors from different specialties, as well as the Doctors Syndicate and the Forensic Medicine Department. Cases are referred to this committee by the Prosecution before going to court.
The draft law, according to Dr. Alaa Ghannam, one of the co-drafters, includes insurance on doctors and operations through specialized firms, as happens in the US and Europe.
But for nearly four months, since 20/5/2015, the Ministry of Health alone forms committees pursuant to ministerial decree 343 of 2015 to study medical cases and determine whether medical errors have taken place.
Ghannam said the ministry has implemented the law partially, saying the presence of a fourth entity to receive complains from victims adds nothing new.
Secretary General of the Doctors Syndicate Dr. Mona Mina considered that the formation of committees in this way will not solve the crisis as each entity will continue to operate alone.
She called for making these committees part of the draft law on medical responsibility that the syndicate drafted. She also called for adding representatives from the Doctors Syndicate, Forensic Medicine, and civil society to the committee on medical errors, and for coordination among the relevant authorities as well as for tackling legal loopholes. Only this can fulfill medical justice, she said, and preserve the rights of both patients and doctors.
* This investigation was carried out with the support of Arab Reporters for Investigative Journalism (ARIJ) www.arij.net.