Magistrate finds no negligence by doctors who treated Stephen Mangion

The magistrate investigating Stephen Mangion’s death in the waiting area of Mater Dei Hospital’s emergency department has found no negligence from doctors who treated the man.

Magistrate Joe Mifsud concluded that the medical staff who dealt with Mangion on the telemedicine helpline, at the Floriana health centre and Mater Dei could not have “reasonably diagnosed” Mangion’s condition. The magistrate also recommended the proces verbal be published to allay public alarm caused by the death. 

The proces verbal was published in its entirety by the Health Ministry on Tuesday after its conclusions were leaked by the media.

The ministry published the magistrate’s report without making any comments but is holding a press conference on Tuesday afternoon.

The magisterial inquiry is distinct from the independent inquiry the ministry set up after Mangion’s untimely death inside the hospital emergency.

Symptoms described by patient were atypical

According to the magisterial inquiry, the autopsy revealed that Mangion died of a cardiac tamponade caused by an aortic dissection. An aortic dissection happens when a lesion occurs to the inner layer of the aorta, which is the main artery through which blood flows from the heart to the rest of the body. The lesion allows blood to enter among the layers of the aortic wall.

An aortic dissection is considered a serious medical condition and can be fatal unless treated immediately. It can cause a lack of blood flow to the body’s vital organs and deterioration can be sudden.

However, the magistrate found that the symptoms Stephen Mangion had described to the telemedicine doctor, the doctor at the Floriana health centre and the triage nurse at hospital emergency were not consistent with symptoms normally associated with aortic dissection.

The situation was more complicated because Mangion suffered from high blood pressure but had stopped taking medication for it. High blood pressure increases the risk of aortic dissection.

Three ECGs ruled out heart attack

Also, Mangion was subjected to three ECGs – one at the health centre and another two at Mater Dei – with doctors each time excluding a heart attack.

The inquiry did find that when the health centre doctor suggested that Mangion go to hospital, no ambulance was available but given the exclusion of a heart attack, the fact that the person accompanying Mangion and who offered to drive him to hospital was a nurse, and the relatively short distance between the health centre and Mater Dei, the health centre doctor did not feel there was any risk.

At the time, Stephen was in hospital there were 22 urgent cases like his, eight of which had chest pains.

In his conclusion, the magistrate said: “The fact that Mangion was not taking his medication for high blood pressure, sought medical assistance late, 15 hours after he started feeling symptoms, the atypical symptoms he presented himself, which were not specific to aortic dissection, meant that the medical staff could not reasonably diagnose his condition.”

The magistrate ruled out negligence from the medical staff and said there were no grounds for criminal action to be taken.

Magistrate chides Jason Azzopardi for social media comments based on ‘fake news’

The magistrate also chided those who on social media passed “comments” and “poems” on Mangion’s untimely death by basing their observations on fake news peddled by someone who then deleted their Facebook profile.

The magistrate was referring to former MP Jason Azzopardi, who claimed negligence, and two private individuals, one of who even wrote a poem trying to describe what he believed were the final moments of Mangion.