A fatal delay in treatment: the baby was infected with a bacterium and died - Sheba will compensate his family with millions
The baby was born at 35+2 weeks and his condition was defined as good and stable, but at the age of five days he died from an infection. The court determined that the antibiotic treatment was delayed by about two to two and a half hours and that the state did not prove that it took reasonable measures to prevent the infection. Sheba: "The case is exceptional and painful, the lessons learned led to an improvement in procedures."
Medical negligence caused a premature baby to contract an infection and die in the neonatal unit at the government hospital Sheba in Tel HaShomer. The hospital will pay compensation of about 2.2 million shekels, including legal fees and expenses, to his parents and twin sister - this was determined on Thursday in a ruling by the Tel Aviv District Court, delivered by Judge Orly Mor-El.
The ruling accepted the lawsuit filed by the parents and the estate of a baby who died at the age of five days after being infected with a violent and resistant bacterium. Judge Mor-El determined that the state, which is the owner of Sheba Hospital, failed to prove that it took reasonable measures to prevent the infection, and that there were also failures in the treatment of the baby after signs of infection appeared.
The case occurred in October 2011. The baby was born prematurely at 35+2 weeks, along with his twin sister, weighing 1,829 grams. After birth, his condition was described as good, vital, and alert, and in the first days of his life he remained stable. On the fourth day, after a culture taken from him was negative, antibiotic treatment was stopped. Later that day, he suffered from two episodes of apnea and a drop in oxygen saturation, and at 15:00 his temperature rose to 38.3 degrees.
The treatment was delayed by about two and a half hours
The court determined that at this stage there was a place to conduct an investigation and start antibiotic treatment within a reasonable time. However, the treatment actually began only around 18:30. The judge determined that there was a delay of about two to two and a half hours and that "the prolonged waiting that occurred in this case until the shift change is unreasonable."
After midnight, his condition deteriorated rapidly: he looked pale, his body temperature dropped to 35.8 degrees, and he was urgently transferred to intensive care, where he was intubated and received Meropenem. In retrospect, it turned out that he was infected with a resistant Enterobacter ESBL bacterium, which was sensitive only to this drug. Despite resuscitation efforts, his death was declared at 03:10. The ruling noted that there is no dispute that if he had received Meropenem in time, it is likely that the infection could have been brought under control.
However, the judge did not determine that the strongest drug should have been given immediately upon the appearance of fever. She accepted the position that it was reasonable to start with a second-line antibiotic, but determined that if the treatment had started earlier, it would have been possible to examine earlier whether it was ineffective and switch to Meropenem. In practice, the drug was given only after 01:30, and the court determined that a link was proven between the delay in treatment and the baby's chances of survival.
Another central part of the ruling dealt with the actual infection in the neonatal unit. The evidence showed that during that month, four babies were found in the hospital with bacteria in their bloodstream and 14 other babies were carriers of ESBL bacteria. Following the findings, steps were taken, including periodic screenings, isolation of carriers, and tightening of precautions. The court determined, based on a study presented in the proceedings, that it is likely that the source of the bacterium was in the neonatal unit and that the probability of infection from the staff is higher than the probability of infection from the parents.
The state did not prove that reasonable caution was taken
The judge criticized the state for not presenting the epidemiological survey itself and not bringing professionals from the infectious diseases unit to testify. It was also noted that a few months earlier, an outbreak of another resistant bacterium had already occurred in the neonatal unit, during which a baby died, other babies were infected, and the neonatal unit was closed to new admissions. Under these circumstances, the court determined that the state did not meet the burden of proving that reasonable caution was taken to prevent the infection.
Alongside this, the judge emphasized that during the trial she was impressed by the "skilled and dedicated staff, who worked under difficult conditions," and that the staff acted with good intentions. According to her, the defendant is the state, which is responsible for the hospital's operation and staff guidance, and not the doctors themselves, "who tried to do their best under the conditions and with the knowledge they had in real time."
Advocate Ilit Raphael, who represents the family, says that "the ruling concerns the very unfortunate and unnecessary death of a baby who was born healthy at a very advanced week. The fact that continues to bother is that it seems the hospital moved on, as if nothing happened. The hospital did not investigate the incident, certainly did not analyze it, and did not even report it to the Ministry of Health. So there is no in-depth examination, no lessons learned, and no prevention of other such cases.
"This conduct of the hospital is simply incomprehensible - that a healthy baby died because the staff, who did not maintain hygiene, infected him with a 'hospital' bacterium, and the hospital, contrary to explicit instructions in the law, does not involve the Ministry of Health. Problematic conduct, to say the least."
Sheba: "The lessons learned led to an improvement in procedures"
Sheba Hospital responded: "This is an exceptional and extremely painful case, which occurred about 15 years ago and is still well remembered by us. As the judge determined in the ruling, the staff who treated the case was professional, skilled, and dedicated.
"Alongside this, the incident and the lessons learned from it led to the tightening and improvement of procedures and protocols in our neonatal unit and in all neonatal units in Israel, with the goal of continuing to improve the care provided to premature babies.
"The neonatal unit at Sheba is one of the leading neonatal units in Israel, and every year it receives the highest ratings in the quality and safety indicators of the Ministry of Health. We are committed to continuing to operate according to the highest professional and safety standards, and to provide all our patients with professional, safe, and humane care."
