The Esfakis Inquest and What it Means for Bahamian Healthcare

by Leandra Esfakis

•The author is the deceased's sister, and an attorney. Their father was the late Dr Andrew Esfakis.

Last month the Coroner’s Court delivered a verdict in the April, 2002 death of Christopher Esfakis, age 42, of “Death by natural causes, with a substantial and significant contribution made by neglect.”

Christopher Esfakis’ death was “natural”, in the ordinary meaning of that word, the same way that every death is natural: his heart stopped beating. The inquest determined, however, that “neglect” contributed significantly to that death.

According to the evidence, Christopher Esfakis walked into Doctors Hospital about 1 am on Saturday April 20, 2002. He was admitted for treatment for mostly first and second degree burns to 25 per cent of his body. He died the following Monday at 7 pm.

Mr. Esfakis’ condition on Saturday morning was stable, and he had no complaints. At noon Saturday, he was administered an excessive amount of IV fluid, and excessive fluid orders continued. He then began to swell, and complained of breathing difficulties over a period of 10-12 hours.

Early Sunday, Mr. Esfakis suffered serious injury when his upper airway obstructed, and he was found “cyanotic” - blue from lack of oxygen. At this point doctors responded, and after several failed attempts to forcibly intubate, he underwent a tracheotomy Sunday morning.

After the tracheotomy, his condition became critical. A third line of IV fluid was added, and the fluid load increased, as did urinary output, indicating over-hydration. Apparently, no effective steps were taken to correct the over-hydration.

Mr Esfakis died Monday evening of (i)“cardio-respiratory arrest, acute pulmonary congestion and oedema; and (ii) airway obstruction due to inhalation injury.” His internal organs were “unremarkable except for the features of congestion,” the autopsy report said.

According to medical evidence at the inquest, Mr. Esfakis had a “95%-97%” chance of surviving his burn injuries. The evidence further indicates that the care given at Doctors Hospital eliminated his very high chance of survival, and that Mr. Esfakis’ primary care physician persisted in a course of treatment which he plainly ought to have known was wrong.

In court, one doctor blamed the patient himself, for lack the failure to intubate, and also the primary physician. Meanwhile, the primary physician seemingly blamed the nurses for certain failures. No-one can take any satisfaction from this substandard performance.

The verdict of the Coroner’s Court represents an accurate history of the facts, and conclusions reasonably made from those facts. The outcome of this inquest is important - and not just to the widow and family of Christopher Esfakis.

It is important to the Bahamas, at a time when the judicial system is under attack for being dysfunctional, as the inquest confirms that the judicial system can work: witnesses were called, evidence heard, and a verdict delivered - albeit over five years late.

But this inquest is not about “winning” the case. There can be no such outcome for any party concerned. We have needlessly lost Christopher. We lost the future of the Esfakis family. A doctor may have lost his reputation. A hospital is shrouded by a cloud of doubt. For all concerned, this is about dropping the ball - the heartbreak of failure.

A “quality assurance” programme and proper burn protocols would have protected both the patient and his caregivers. Christopher would be alive, and the medical staff would not have the unenviable difficulty of defending the indefensible.

It is well for patients to be vigilant about their health care. But most are not in a position to second-guess a doctor, who is ultimately responsible for a proper diagnosis and treatment plan. The evidence given in the Esfakis inquest, raises issues which require a response from the relevant authorities. These would include the Medical Council and the Hospital and Health Care Facilities Board.

The Medical Council is responsible for “the proper conduct” of its registered doctors. “Improper conduct” includes matters such as incompetent care and abandoning a patient. This case also raises issues of “quality control” that should concern the Hospital Board. The evidence in Christopher Esfakis’ case indicates:

1) a breakdown in communication between medical staff and nurses.
2) the failure of nurses to appreciate the significance of an extraordinarily high urine output.
3) a failure of communication between nurses on change of shift.
4) a lack of sufficient, or sufficiently qualified medical staff to respond appropriately or at all, to Christopher Esfakis, when the nurses warned that his condition had become critical.
5) a failure to advise Christopher Esfakis or his family of the diagnosis of inhalation injury, and its prognosis.
6) A failure to keep or provide complete and unadulterated medical records.
7) A failure to refer Christopher Esfakis to an appropriate treatment facility in a timely fashion.

There seems to be no line of recourse for the nurses, when calls to the primary care physician, and the emergency room physicians fail to produce any effective response. From the records available, there appeared to be no protocol giving the nurses access to the Chief Medical Officer, or any other medical staff. The patient was simply left to his fate.

These are matters which require a response from the Hospital Board, which licenses Doctors Hospital. The complaint has been before the Hospital Board since 2005 and successive Ministers of Heath have promised an investigation, which still awaits action.

The hospital is required by law to file reports of deaths on its premises to the Chief Medical Officer of the Ministry of Health. Apparently this does not happen. Data from these reports could be useful to an oversight committee of the Board.

In North America hospitals function with “quality assurance” committees. The Hospital Board could compel Doctors Hospital, or any licensee, to form an affiliation with, for instance, Harvard University Hospital, which offers help in this regard. This would give Doctors Hospital the ability to self-regulate with objective assistance. It would also commercially benefit Doctors Hospital, to claim a prestigious “quality assurance” alliance.

Harvard offers outreach programmes, to advise on setting up self-regulatory systems, and also offers educational and remedial input when problems are identified. Over time, the Hospital Board should receive progress reports from Doctors Hospital, and the outside authority.

The Hospital Board could then consider licensing around those reports. The Board should also, in its own due diligence, examine a few cases a year, from randomly chosen files, as a matter of routine, and take outside expert advice on the quality of health care management, as shown in those files.

Public safety requires the Medical Council and the Hospital Board to carry out their mandates. Some “quality control” monitoring, and appropriate protocols need to be in place. Patients must have some degree of assurance that trusting their doctor/hospital is reasonable, because certain standards are going to be met. Any relationship between a patient and his doctor or hospital which does not include basic trust, is likely to be dysfunctional.

The standard of care should also concern health insurance companies, who with the patient, bear the cost of inappropriate care. Their positive participation in the quality assurance process would also be beneficial.

Christopher Esfakis’ case presents an opportunity to examine and rectify failures, and save lives. This is what the medical profession is called to do.

Comments

[glass half empty]

:( ....

not gonna happen

.... ):

[Kimberly]

I am so sorry for the entire Esfakis family, and cannot imagine what they are going through at the moment. Dr. Andrew was my father's physician for many, many years.

[Willie]

The Esfakis case is important to the Bahamian public because it demonstrates that professional incompetence is not acceptable and cannot be swept under the rug as most believe has been the usual outcome.
It also demonstrates that the Rule of Law may still be alive and surviving in the Bahamas.

[Personal Health Records]

Good health care service which offers good health care system