Updated: Health Ministry welcomes Ombudsman recommendations on Baby AB death

Updated with statement from Health Ministry at 6:35pm

Ombudsman Joe Said Pullicino said the parents had no clear answers or counselling in their moment of anguish and left with no support from the hospital staff, with the exception of the Chairman of the Department of Paediatrics, because a magisterial inquiry was launched into the death of their child.

The Health Ministry said it welcomed the Ombudsman’s report on the matter and will be taking his observations very seriously.

"The ministry is deeply saddened by the untimely death of Ms AB’s young child back in December 2009. It is because of cases like this that Minister Joe Cassar has been advocating the introduction of a Commissioner for Administrative Investigation (Health Ombudsman) within the Ombudsman’s office who can ascertain patients’ rights within Public Health Care Services," the ministry said.

Discussions to this effect have been held with the Ombudsman. Currently the Ombudsman Act is at Committee Stage in Parliament.

On 24 December 2008, the complainant (Ms AB) and her partner took their 16-month old son to Mater Dei Hospital where he was examined and diagnosed with croup and after receiving advice on the treatment that the child needed, the boy was discharged.

For the next three days the parents administered the medication that was prescribed for their son but early in the morning of 27 December before Ms AB’s partner left for work, he discovered to his great shock the child’s lifeless body in his cot. Attempts at resuscitation at Mater Dei Hospital where the child was taken urgently by ambulance were unsuccessful.

Following a request by the hospital authorities, an autopsy was carried out on 29 December 2008 and the death certificate ascribed the cause of death to pneumonia.

However, since only three days earlier their son was healthy and showed no signs of any sickness, the couple considered this diagnosis as too vague and demanded an explanation from the Mater Dei management.

To their surprise, however, the hospital management gave no answer but pleaded that the case was the subject of a magisterial inquiry that was conducted by the Court, and refused them a copy of their son’s medical records.

The magisterial inquiry was completed on 5 August 2009 and concluded, that there was no mismanagement by medical staff at Mater Dei Hospital.  

However, when on 24 September 2009 the child’s parents finally obtained a copy of the report from Attorney General’s Office, they were distressed to find that in their view the inquiry contained incorrect information.

The Ombudsman was able to get hold of these documents, showing that Ms AB’s son was already dead on arrival at Mater Dei Hospital and that when attempts at resuscitation failed, the hospital authorities informed the Police for the purpose of holding a magisterial inquiry. This is standard procedure in cases of sudden unexplained deaths.

“It is the opinion of the Ombudsman that this attitude towards complainant and failure to provide any support to the parents on the grounds of an ongoing magisterial inquiry was wrong, uncaring and insensitive.

“It is also the Ombudsman’s opinion that it would have been in the interest of the health authorities themselves to set up an internal inquiry alongside the magisterial inquiry especially when only three days before his death the child had received treatment at the Mater Dei Emergency Department,” Said Pullicino said. 

According to the Ombudsman it would also have been appropriate to hold such an investigation to establish the facts should civil court action be instituted for alleged negligence or for any other failure in the treatment and for which the hospital could have been held responsible. 

In his recommendations, the Ombudsman said the health authorities should ensure that, unless debarred by a Magistrate, they should set up an internal inquiry whenever this is in the interest of patients or of their relatives or even of the hospital involved.

“Public hospitals should have in place a programme for implementing essence of care communication guidelines aimed at addressing situations that cause or are likely to cause distress to patients and their relatives,” the Ombudsman said.

He also encouraged a protocol, based on a recognition of the established right of patients to see their medical records, to be issued as a matter of urgency with clear written instructions to hospital staff on how to deal with requests for the medical records of patients either by patients themselves or by authorized persons.