Nurses are ‘out of stock’ | Paul Pace

Three weeks have passed since Joe Pace was arrested on manslaughter charges. But in the meantime, a number of discrepancies have emerged. For instance: at the MUMN press conference on May 4, you said that: “there has never been an inquiry about the incident.” Yet when pressing charges, the police themselves claim to have acted ‘on the basis of a magisterial inquiry’s conclusions’. Can you clarify this apparent contradiction? Was there an inquiry, or wasn’t there?

Let me put it this way: we later discovered, after that press-conference, that there WAS, in fact, a magisterial inquiry.  But what I found very strange, is that… the magistrate never called in either Joe Pace himself, or any other nurse, to hear their version of events.

This is, in fact, why I had earlier thought that there hadn’t been any inquiry at all. Because - even if it turns out that there was one, in the end – the fact remains that we ourselves didn’t know about it, throughout these past five years.

And personally, I can’t even conceive of a magisterial inquiry, where the main stakeholders are not even given the opportunity to testify; and where the magistrate reaches his or her conclusions, without even talking to any of the people involved.

Now: I am not a legal person, myself; but I do know that, usually, in an investigation you have to hear all sides of the argument. You have to interrogate people; and get to the bottom of what really happened.

In this case, however: first of all, the magistrate took nearly five years, to conclude what should really have been a very straight-forward inquiry. And secondly, none of the main witnesses – including the accused himself – was even called in for questioning. So much so, that not even Joe Pace himself knew that there was an inquiry going on! It’s something we all found about, much later…

Meanwhile, you also argued that – while Mr Pace himself may end up bearing the brunt of the legal responsibility - the blame really lies with the Health Ministry, for failing to provide enough nurses in the first place. This chimes in with your earlier claims (specifically with regard to the COVID pandemic) that the nursing profession was facing a full-blown ‘crisis’. First of all: does this mean the COVID nursing crisis is still in full swing today?

First of all, there has always been a shortage in the nursing profession, from long before the pandemic. But what happened is that COVID-19 exacerbated the problem, to such a degree that: yes, we can now refer to it as a ‘crisis’.  And a major one, at that.

To give you a rough idea of how bad the situation has become: the official figures have always been kept secret by the government, but I can confirm that over 400 nurses – from both government and private sectors - have left the service, since the beginning of the pandemic.

And now, we are such in a state that… not only are there not enough nurses for ‘constant watches’ [of the kind that was needed by the patient, in the Joe Pace]; but there is not a single ward, anywhere in the health sector, that is not currently registering a huge number of vacancies… including, naturally, Mount Carmel.

So while COVID did make the problem much worse – not just for Malta, but also world-wide - the reality is that Malta did not do what other countries did, when faced with the same crisis.

For instance: other countries responded by forking out money from their own pocket, and going on an international recruiting drive. In fact, many of those 400 nurses were actually poached by other countries: primarily, the United Kingdom. We even had representatives of the NHS coming to Malta, to conduct interviews with prospective nurses; and I can even tell you at which local hotel those interviews took place, too…

And if they succeeded, it’s because they offered very favourable conditions: including lodging; accommodation for family members; better salaries, and so on. So naturally, I don’t blame those nurses for leaving… especially, the young ones. But still: the crisis is there; it’s real; and now, it’s being felt more than ever.

Just to give you a few other examples: there are cardiac-monitoring beds, at Mater Dei, that are currently not in use, because of the lack of trained nurses. At St Vincent de Paule, there are currently around 150 beds that are vacant, for the same reason.

Now, we even have problems at the Renal Department: where there are renal machines, but no nurses to actually operate them. So basically, it’s beginning to affect the health service as a whole…

Are you suggesting then, that the patient in question was actually a victim, not of ‘criminal negligence’ at all, but of the system itself?

Yes: you could put it like that, if you like. What I myself said at that press conference, though, was that this is another case of ‘out-of-stock’. As everyone knows, there are often times in this country when certain medicines are ‘out of stock’; and when that happens, the unfortunate reality is that… we simply can’t administer medication, when there isn’t any to administer.

It is exactly the same in this scenario, too. As things stand: we have about 60 ‘Level-1’ cases in Mount Carmel – and another 70 at Mater Dei – when, quite frankly, there aren’t anywhere near the ‘60 nurses’ that are needed to actually provide Level-1 care. It’s as simple as that, really. Nurses are ‘out of stock’…

Excuse my ignorance, but: what does a ‘Level 1 case’ mean, exactly?

To put it as simply as I can: ‘Level 1’ is when a doctor prescribes that a particular patient needs dedicated, ‘one-to-one’ care: which, in this context, means being within one metre of a nurse… at all times, 24-7, every day, every night.  Which is no joke, believe me…

But it’s a necessary procedure, of course; usually prescribed for highly critical patients, where there is real danger of death or injury. And as I was saying: we currently have 60 of those at Mount Carmel… and 70 at Mater Dei.

This is why, for us, this has all along been a ‘ticking timebomb’. We knew, from beforehand, that there simply aren’t enough nurses, to provide Level-1 care for all the patients that need it. So it was inevitable, that we would sooner or later end up with cases like Joe Pace’s. Because he isn’t the only one. There were, in fact, another three similar cases before this one. And those are the ones that ended up in court… where patients either died, or self-harmed, etc.

The stark truth, however, is this sort of thing happens all the time. Even now, as we speak: though five years have passed, since that particular incident, it is still an ongoing issue, today. Inevitably, some of those Level-1 patients do end up without receiving Level-1 care…

And it was also inevitable that the nurses themselves would take all the blame for it, in the end. Like we always do. And in this particular case: unfortunately, the blame had to fall on Joe Pace, of all people…

Nonetheless, there still remains the question of who SHOULD really take the blame, in such cases. From the perspective of the victim’s family members, for instance: if one’s relative dies, while supposedly under 24-7 hospital observation… isn’t it only natural that they might hold the hospital staff responsible?

Look, let me put it to you this way: Joe Pace’s main responsibility, as manager of Mount Carmel Hospital, was first and foremost to cover what we call the ‘complement’: basically, the minimum number of nurses to be assigned to each and every single ward.

In both Mount Carmel and Mater Dei, that number is supposed to be six. In practice, however, we’d be lucky to have three. So Joe Pace’s first headache is always going to be to ‘try to get the complement right’: which is never even possible, to begin with.

When it comes to the Level 1s, however: usually, there is no staff at all. And everybody involved in the entire healthcare administration – from top to bottom: all the way up to the minister himself – knows this perfectly well. They know, as well as I do, that those cases are simply not being covered at all.

So it is pointless for doctors to keep issuing Level-1 supervision orders: when we all know (including the doctors themselves) that there simply aren’t enough nurses to actually carry them out.

In fact, after the Joe Pace case, government itself entered into an agreement, to start supplying nurses through a private contractor. Unfortunately, however, the private contractor has failed to actually deliver, to this day. It seems that he, too, couldn’t cope with the sheer number of cases: despite being bound by a contract to do so.

So much so, that he ended up sending carers, instead of experienced nurses … and even that failed. Which incidentally also means that there even aren’t enough carers – let alone nurses - to cover the case-load, either.

But basically, what it all means is that the system itself is still failing, to this day.  And this is why I hold the ministry responsible, for what happened at Mount Carmel. Because, just like us… they knew. And I know that they knew: because we raised this issue with them during countless meetings, over the years. And yet, they did nothing to actually address the problem: beyond, as I said, hiring a private contractor… which, in any case, didn’t even work…

How, then, can you possibly blame the nurses? Or Joe Pace, in particular?

Earlier you mentioned that ‘everyone’ – including the doctors – knows about this problem. Am I right in interpreting that to mean that you expect more co-operation, from your colleagues in the medical profession, than you are actually receiving?

No, no, I wouldn’t say it’s a question of ‘co-operation’, or anything like that. And just in case I gave you the wrong impression:  I certainly don’t ‘blame the doctors’, either.

For one thing: they’re the experts, at the end of the day. And if a doctor decides that a certain patient requires a certain type of treatment… who I am, a nurse, to argue?

Besides, the reality is that doctors have just about as much control over the situation, as nurses do: or as Joe Pace himself did, for that matter…

At the same time, however: it is an issue that affects them, too. In Malta, for instance, there is a law which ultimately holds doctors responsible, for the well-being of their patients.

So we do inform them, on a routine basis, that… “Listen: that ‘Level-1 you ordered? Sorry, but it couldn’t be done. No nurses available…”

So while the doctors themselves are not to blame: then again, this is also why I compared the situation to ’out of stock’ medicines, earlier.

What happens when a certain medication is ‘out of stock’, anyway? We inform the doctors, of course; and usually, the doctor will try to order something that is similar to that medication.

When it comes to nurses, however; when we likewise inform doctors that it is now ‘nurses’ – not ‘pills’, or ‘tablets’ – that are ‘out of stock’… what they usually say is: ‘Not my problem. Call top management; call the minister; call whoever you like; but it’s not my problem…’

And in a sense… they’re right, too. It is, after all, what we’ve been saying, all along: i.e., that the responsibility to provide more nurses all along lies with the government – and the health ministry, in particular – and certainly not the doctors; or, even less, the nurses.

But then… it’s a lot easier to just ‘blame the nurses’, isn’t it? We are, after all, at a much lower level in the medical hierarchy…