Medical Accountability in the Bahamas

by Larry Smith

It has been almost four years since former Health Minister Dr. Marcus Bethel directed the Hospital and Healthcare Facilities Board to investigate a complaint into the treatment of a 42-year-old man who died at Doctors Hospital in 2002.

Yet to date, there has been no effort by this public board to address the matter. In fact, its chairman, Dr Kirk Culmer, was quoted in a recent Tribune report as saying that the board did not want to be "bothered" with that kind of investigation.

The complaint by lawyer Leandra Esfakis alleges that the failures within Doctors Hospital to comply with the legal requirements of the Hospital and Health Care Facilities Act resulted in the death of her brother, Christopher Esfakis, three days after he admitted himself for the treatment of first and second degree burns from a household accident.

The Hospital and Healthcare Facilities Board was created by Parliament in 1998 to license private hospitals and clinics. One of its chief responsibilities is to investigate complaints from the public, but it has no record of ever doing so.

The complaint against Doctors Hospital has been ignored under three successive ministers of health, although the law provides for the Board to select experts to probe a complaint, and then tell the hospital what to do in order to renew its license - the object being to improve the delivery of healthcare to the public.

Earlier this year, a judicial inquest into Mr Esfakis' death delivered a verdict of “death by natural causes with a substantive and significant contribution of medical neglect.” The principal doctor involved in the case is applying for a review by the Supreme Court to quash the verdict. A date for the review has been set down for July.

Evidence given in Coroner’s Court was that Mr. Esfakis had a more than 90 per cent chance of survival. And during the inquest, medical staff involved in his care did not dispute their failure to implement standard treatment for a burns patient with symptoms of inhalation injury. Nor did they dispute that Esfakis was administered an excessive amount of intravenous fluid.

According to the evidence, Esfakis received 60 litres of fluid over a period of 66 hours. He weighed about 130 lbs on admission, but his weight at autopsy was 190 lbs. The attending forensic pathologist told the court that the state of the patient's body at autopsy was consistent with drowning due to the administration of excess fluid.

"Neglect is part of the verdict which I think needs to be explained," said Coroner William Campbell last February. "It is defined as gross failure to provide adequate nourishment or liquid or procure basic medical attention or shelter or warmth for someone who is in a dependent position, because of (in this case illness), and who cannot provide it for himself...On this definition, the opportunity for rendering care was not taken, and this failure caused death."

The coroner went on to say: "This was not a complicated medical case where there were legitimate differences over optimal treatment options each having its own distinct dangers. Here there was no debate or agonizing over treatment options. It was a basic and straightforward issue...It is no exaggeration to say that Christopher Esfakis's 90 per cent chance of survival was frittered away by the cumulative errors of neglect in his medical care."

But the response of medical regulatory bodies - and of Doctors Hospital itself - to Esfakis' death has been nothing short of astounding, at least to this writer. And despite an assurance given by the new Minister of Health, Dr Hubert Minnis, at a public forum last year that the complaint would be investigated, “according to legal process”, the Hospitals Board has done nothing but stonewall it.

In correspondence over the last four years, the Board claimed it did not have the means to conduct an investigation. And in remarks at a Rotary Club meeting last month Dr Culmer went so far as to say that the legal requirement for official notification of hospital deaths was "antiquated and unnecessary". He claimed that regulatory authorities do not need to know how many people die in a healthcare facility.

Contrast this attitude to the response of the British Health Commission when it recently noted a high rate of deaths at a London hospital. An inquest was quickly held and special measures were implemented at the hospital until the death rate dropped. This story is available online at:
http://www.guardian.co.uk/society/2008/may/30/mother.dies.

In the British case the coroner ruled that a woman's death from massive bleeding after she gave birth by caesarean resulted from neglect and failings in the maternity unit. Her death was the tenth at that particular hospital's maternity unit in three years, and it led to a thorough investigation by the authorities.

The brick wall raised in response to the Esfakis complaint begs the following questions: Why is the Hospitals Board refusing to track the death rate in the facilities that it licenses? And why does it want this provision revoked? Without a record of the death rate, and investigations of an unusual death rate, it is impossible to determine whether the Bahamian counterpart to a Dr. Harold Shipman, for example, is practicing here.

Shipman was the genial British GP who murdered over 200 of his patients before being convicted in January 2000. His trial led to a two-year inquiry into Britain's healthcare regulatory system together with a full review of relevant legislation. And believe it or not, the killing spree was only discovered by a local coroner who became concerned about the high death rate among Shipman's patients.

Of course, no-one is suggesting that a Harold Shipman actually is practising medicine here - the analogy is used only to draw the point. If the Hospitals Board refuses to track death rates, or to probe legitimate complaints backed by extensive evidence, then opportunities to improve the delivery of Bahamian healthcare will clearly be lost, to put it mildly.

Not only has the Hospitals Board never investigated any complaint - and now explicitly refuses to do so, even in the face of ministerial directives - it also wants that power revoked. In other words, it wants private clinics to be totally deregulated.

If that happens, there will be no accountability under the law in the healthcare sector for fatalities or other misadventures. And surprisingly, although Board members have, or have had, an interest in Doctors Hospital, they continue to claim that no conflict exists.

A few years ago, health industry expert Nadeem Esmail of the Vancouver-based Fraser Institute wrote a paper for the Nassau institute on the government's proposed national health scheme. In that report he discussed regulatory options for medical facilities as follows:

"The certification of practitioners and facilities should be maintained by independent third parties, which could be any of several licensing bodies in Canada, the United States, or Europe, or independent quality certification organizations that also practice in these regions.

"Certification by an independent, reputable, and preferably offshore third party would provide the quality signal desired by the Blue Ribbon Commission (on national health) and likely by many Bahamians, while a lack of local oversight over the certification process would ensure that harmful political intervention would be constrained.”

It is a fundamental principal that every human being has a right to life. Without some external accreditation process, which is not interfered with by local directors protecting their colleagues (and their own) interests, that right to life - while in hospital care - is clearly at risk.

The Esfakis complaint is a case in point. Christopher Esfakis’ right to life was ignored, and according to the inquest evidence, put at risk by the treatment he received from medical staff at Doctors Hospital. That treatment persisted until he died, and the Hospitals Board refuses to investigate the matter.

Revenge for a loved one's death is decidedly not the issue here. That can be pursued in the courts if need be. What is at issue is for the living to be able to rely on physicians who are committed to processes that enhance their patients' survival rate. To achieve that, we need a real healthcare commission to handle complaints about medical failures in both private and public facilities, and it must be willing and able to address any failings.

Where are those good doctors and administrators who are concerned enough about their reputation and the survival of their patients to lend support to an independent, reputable third party certification programme for our hospitals? Do these medical professionals exist?

And since the Hospitals Board has insinuated that it does not wish to protect the public interest, what is our government going to do to ensure that citizens are protected from harmful medical practices?

According to Leandra Esfakis, "All we are asking is that they get their professional lives in order. There is no recompense to us for the damage they did to our personal lives. The distortions, evasions and malicious allegations don't matter because nothing can cut deeper than what has already happened. And the plain fact is - it could happen to anyone."

In an effort to inform the public on healthcare laws and related issues, Ms Esfakis has launched an interest group called Bahamas Patient Advocacy, which aims to provide a platform for citizens to have their voices heard, and become pro-active in defense of their healthcare. Constructive input from medical professionals is welcome, she says.

She has posted an online petition at www.bahamaspatientadvocacy.org to urge the government to fulfill its obligations in this regard.

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