Chairman of the Board of the Celje Hospital Andrej Klasinc resigned after the discovery of the identity of two patients in the Celje hospital, the Ministry of Health confirmed. Tarča was the first to report on this. Klasinc is one of the five representatives of the government on the institute’s council.
About his dismissal and that of a member of the hospital council Primož Stošicke the government is supposed to discuss at Friday’s correspondence session, reports the portal 24ur. Instead of Klasinec and Stošicke, the government should appoint the Celje hospital council Mojca Kert and Tadeja Hata.
The management of the hospital submitted their resignations last week, but the institution’s board did not approve them.
That is why the government dismissed the founder’s representative at the hospital in Celje Mitjo Pirman and appointed instead Tomaž Subotica.
Complaint to the management of the Celje hospital
As announced by the Ministry of Health, during the extraordinary internal control procedure, it was established that all the medical documentation for each of the two residents in separate folders with all identification data and a health card had been handed over to the paramedics of the Sevnica Hospital.
At the same time, the ministry warns that “the fact that when going to the hospital both residents were dressed in their own clothes, on which there were identification tags with the resident’s last name and first initial, will stand out”. At the same time, they point to another unusual circumstance that could be according to the ministry, perhaps important, if not even crucial, for clarifying the extraordinary event in the Celje hospital – survivors the patient when he returned to the retirement home, he was wearing his trousers, which were marked with his real name, while all the accompanying documentation referred to another the patienthe also had a bracelet on his arm with wrong information or someone else’s information the patient.
Due to the unusual circumstances and obvious inconsistencies that occurred upon admission and during treatment at the Celje hospital, the Ministry of Health will file a complaint with the law enforcement authorities against the management of the Celje hospital due to objective responsibility and suspicion of the criminal act of causing death through negligence. The control process did not show any error, irregularity or shortcoming committed by the staff of the Trubar Retirement Home Loka pri Zidanem Most when handing over to the rescue transport, before or after the handover, they wrote.
Medical Chamber: The complaint is premature
The Medical Chamber of Slovenia considers the Ministry of Health’s complaint against the management of the Celje General Hospital for causing death due to negligence to be completely premature. Therefore, they support comprehensive professional and administrative supervision in the form of systemic supervision ordered by the Ministry of Health and participate in it, they wrote in the press release.
The Act on Health Care Activities provides that the competent commission in the supervision procedure shall carry out all supervisory actions necessary for the clarification and adequate analysis of all the circumstances of a specific case. The commission submits a final report on its findings and in it proposes measures that are appropriate and necessary based on the results of the control, including the notification of suspicion of a criminal act. “In this case, there is no such report yet, as the procedures for appointing members to the commission were only underway this week,” they explained and warned that such an approach enforces and strengthens the culture of blaming and finding the guilty even before all the circumstances are clarified.
This destroys trust at all levels and discourages people from assuming leadership positions in public institutions, which will further accelerate the disintegration of the public health system. This also does not contribute to the fact that the tragic case could first be analyzed professionally and based on the findings, system improvements could be established to increase patient safety, they believe.
The chamber warns that, both out of respect for the relatives and to preserve the credibility of the decision-makers at the ministry, it is necessary to refrain from partial comments until all the circumstances have been clarified. “Decisions on measures should only be made on the basis of irrefutably established facts, because otherwise the ministry also calls into question the validity of the institute of controls prescribed by law,” they also wrote.
Celje Hospital announces active cooperation in the event of a complaint
Following the Ministry of Health’s announcement that it will file a complaint against the management due to objective responsibility and suspicion of causing death due to negligence in the recent change of patient identity, the Celje Hospital promises active cooperation. At the same time, the hospital once again warned that the extraordinary internal professional control unequivocally showed that the patient, who later died, was treated appropriately for an acute illness. According to the control results, the patient was treated in accordance with the guidelines for the treatment of a detected acute condition, they emphasized.
According to the Celje General Hospital, the interruption in the therapy of his chronic diseases was so short-lived that it did not lead to a documented complication. In addition, the patient was clinically monitored at all times, they wrote. As they stated, they immediately reported the incident to the police themselves and gave them all the required information, and they will actively cooperate with them in advance.
Regarding the constant appeals of the Minister of Health Danijela Bešič Loredana regarding the resignation of the hospital’s management, they reminded that the hospital’s management submitted resignation statements, but the board of the institution did not approve them. They recalled the words of the hospital director Aleksandra Svetelška and professional director Franz Vindisarwho publicly said several times that in the event that external audits prove the sole fault of the hospital, they will immediately resign from their positions themselves.
In the hospital, ever since the discovery of the event of identity change of two patients, they emphasize that they support a comprehensive investigation into the system of treating patients with a reduced ability to communicate and their transition between the institutions that treat them. Only a detailed review of procedures in all institutions and their analysis will help to improve quality and introduce changes that will reduce the risk of similar events in the future, they believe. In their opinion, employees should not be blamed for long-standing system anomalies. With this in mind, decision-makers are expected to avoid criminalizing the event and public pressure on the entire medical staff until the investigation is completed.
More checks in progress
Regarding the event, several other controls are underway, and last Friday the ministry initiated procedures for the introduction of system control. At the same time, the Office for Supervision, Quality and Investments in Healthcare called on the Medical Association of Slovenia and the Association of Health and Midwifery Care of Slovenia to appoint their members to the commission for the implementation of system supervision, which will then be appointed by the office, for the implementation of professional supervision with advice. Control is also carried out by the Health Inspectorate, and the Ministry has also called on the Institute for Health Insurance of Slovenia to introduce separate control, the Minister of Health explained on Wednesday. Danijel Bešič Loredan.
The minister, who did not appear on the Tarča show on Thursday and cited illness as the reason, commented on the events in the morning, even before the announcement of the complaint, on the Dobro jutro show. “Several irregularities have occurred, so I think the hospital management must be held accountable, but we will wait until everything is over. Of course, the public must also know the partial results of these controls, which are not very pleasant and show that in the whole chain, both in the organizational and the professional, errors occurred that must never happen again in our healthcare system,” he emphasized.
The exchange took place in the triage room of the emergency center of the Celje hospital
In the Celje hospital last week, the identity of two patients who were brought from Trubar’s pensioner’s home in Loka near Zidanem Most was changed in the same ambulance. They were accepted and identified on the basis of admission documentation and information from the rescue staff of the Sevnica Hospital, who brought them. During the treatment, one of the patients died, and due to a change of identity, the relatives of the wrong patient were notified of the death. They found out about the wrong identification last Wednesday, when the deceased patient had already been buried.
Extraordinary professional supervision at the hospital showed that the exchange of patients took place in the triage room of the emergency center of the Celje hospital when the patients were handed over by the paramedics to ZD Sevnica for triage. The management of the hospital offered to resign, but the board of the institution did not accept it. After announcing the findings of the hospital’s inspection, the minister said that the hospital’s management was responsible. “Of course, this is all in the domain of the board of the institute, so I expect that in the next steps, the board of the institute will define itself as the supervisory body regarding all inspection control reports and system control, and the procedures will be carried out appropriately, as they should be,” he added.
The management offered to resign after changing the identities of two patients, but the hospital board did not accept it. Minister of Health Danijel Bešič Loredan has repeatedly emphasized in public that the management should take responsibility and resign.