How could a 55-year-old woman, taken by firefighters to the emergency department of the Lariboisière hospital in Paris, for headaches, during the night between 17 and 18 December 2018, have escaped the vigilance of caregivers and be found dead in the waiting area of this service almost twelve hours after admission without being examined by a doctor?
To explain this failure in support, “There is no individual fault of a chaperone, but a series of malfunctions that have not stopped the process leading to the tragedy”, ensures world Professor Dominique Pateron, president of the Collegiate of Emergencies of Public Hospitals in Paris (AP-HP), at the end of his mission of inquiry. At the request of the management of the hospital group and of the regional health agency of the Ile-de-France, this report, published on Monday 14 January, does not address the causes of death – unknown until now – but at “Process” it’s at “Organizations” emergencies of Lariboisière.
On December 17, the patient was brought by firefighters at 6:17 pm, registered at the emergency room at 6:40 pm, then placed on a stretcher in the hall of the “short” circuit, where most of the some people go get treated. A nurse sees her at 7:00 pm and 9:00 pm But when around 10 am a nurse assistant calls her four times – once in front of the emergency room – so that she can finally be examined by a doctor, more than five hours after admission, she does not answer.
At 11.55pm, it is marked as “do do not answer the call » is 1:18, it is declared “Escaping”that is, deleted from the lists. And it is only at 6 am that a caregiver, discovering her lifeless on her stretcher, warns her colleagues and makes the transfer to the emergency room vital. Death is observed after ten minutes of resuscitation maneuvers.
“Patient monitoring does not comply with internal procedures”, says the report. For example, the patient had to be seen at least twice between 21:00 and 01:18, when she was declared “on the run”. And before deleting the lists, it would have been necessary to systematically check all the wristbands of the patients in the surveillance areas, as envisaged by the protocol established after the death in February 2014 under similar conditions of a 61-year-old woman. first aid at the Cochin hospital in Paris.
“Given the extremely difficult conditions of that night, it was not possible”, recognizes Professor Pateron. At the time the patient is called, around midnight, about forty patients are in the short-circuit waiting area, ten of them on stretchers. During the day of December 17th, “The activity was very strong” in the largest emergency service of the AP-HP, with 249 registered passages, against 230 on average.
“The malfunctions are due in particular to the high attendance, the ability of the service to function properly has been exceeded that night”says Dominique Pateron. The presence of paramedics was “According to the estimated program” of the service and the general rules of the organization concerning the sorting and operation of the service examination areas were “Respected” is noted in the report.
There are more structural problems. For example, the “medical report for the activity report” in the emergency department of Lariboisière is lower than the other AP-HP emergencies: with 23.5 doctors where 28 would be needed to reach the group average. .
There would also be a “ global problem of superficial insufficiency » and exam box number. Which leads, according to the fact finding mission, “Almost every evening in a channeling phenomenon” is “A significant number of patients waiting for a medical examination”. Result: this area, located, from the geographical location of the hospital, to accommodate “Many precarious people in difficulty with or without pathology”is “Often saturated and not sufficiently controlled”.
The AP-HP management announced Monday a battery of measures to improve the organization of the Lariboisière emergencies. Reinforcements of medical and paramedical staff are planned, a caregiver is already assigned from 2 January to monitor patients in the hall of sight of the short circuit. All medical and medical personnel will also be “trained or reformed” in the next two months to identity surveillance procedures.