Health ministry publishes inquiry report on Stephen Mangion's death

Health and Active Aging Minister Jo Etienne Abela has released the report from the ministerial inquiry regarding the death of Stephen Mangion, which happened on August 27 at Mater Dei Hospital.

The inquiry, led by Emeritus Judge Joseph Camilleri, concluded that no individual was responsible for Mangion's death. The extensive aortic dissection, which had begun early in the morning, made it impossible to prevent.

According to the report, on the day of his death, Mangion had phoned the Siġġiewi Telemedicine centre at 6:46pm and complained about chest pain he had been feeling since 5:00am that day. "Mr Mangion described the pain in the morning as burning. He took Omeprazole and felt better. He thought that it could be stomach acid. Now it was no longer burning and was worse with movement," the report reads. 

Here, Mangion was advised to go to the Floriana Health Centre, and upon arriving, he was registered and "was seen straight away and he did not wait in any queue."

The report found that one day before Mangion's death, the Mater Dei Emergency Department had seen a particularly large number of people and that this, "always creates a backlog of patients still waiting to be seen from earlier shifts. This situation may take 2-3 days to normalise."

The report notes Mangion was first seen in Mater Dei at 7:10pm, and that some time after 10:00pm, Mangion had collapsed in a corridor and was promptly helped by medical staff and taken to a resuscitation room on a stretcher. Mangion was given CPR for 35 minutes, as the report detailed all attempts by medical workers to revive him to no avail. 

A witness told the inquiring board that "understaffing at the emergency department is now the norm," with the witness noting that workers sometimes do not have time for a break throughout an eight-hour-period, "sometimes even for toilet purposes."

The report noted that on the day of Mangion's death, only doctors in training were seeing patients at the Floriana Health Centre and the centre's fast-track system was not operational by the time Mangion was present.

On Mater Dei Hospital, the inquiring board noted that "human resources were not sufficient to keep up with the exceptional workload on the day," explaining that only one senior decision-maker was present in an area with six critically ill patients. The overloaded emergency department was also seen as a contributor to long waiting times and a source of great stress for healthcare professionals.

"The work environment is not attracting and retaining healthcare professionals, both doctors and nurses. This has to be addressed from all aspects such as work schedule, pay structures and family-friendly measures," the report states. The board also noted a lack of uniformity in digital documentation, listing examples where one system used in the primary health service is not accessible to emergency department doctors.

Among other recommendations, the inquiring board suggested one standard documentation system spanning all healthcare sectors. The establishment of a dedicated ambulance nurses section to keep up with the current workload for ambulances. 

In its conclusion, the inquiring board noted that "no single individual was responsible for the demise of Mr Stephen Mangion." The report also made reference to Mangion's poor health, noting his excessive smoking and non-compliance to treatment for hypertension and hypercholesterolaemia. 

"Long waiting times at the emergency department would be detrimental to any patient... However, in the case of Mr Mangion, it did not make any difference to his demise since the process of aortic dissection was probably occurring since 4:00am..."

The ministry expressed condolences to Mangion's family and welcomed the suggestions as part of ongoing healthcare reforms.