Finn Christian Jagge was 54 years old. He died in the gastrosurgery department at Ullevål Hospital on 8 July 2020. Norwegian Patient Injury Compensation (NPE) believes Jagge died as a result of treatment failure, news wrote last year. In the period 2011 to and including September 2020, there were 19 unexpected deaths at this department. After many reports of concern from patients, relatives and healthcare personnel, Ukom, the National Commission of Inquiry for the Health and Care Service, has investigated two departments at two different hospitals. The two scrutinized departments are anonymised in the report: “Reporting culture and learning from adverse patient events”. One department is the gastrosurgery department at Ullevål. The findings are not encouraging. According to news, this quote is taken from an interview with an employee at the gastrosurgery department. news has also been in contact with a number of sources who describe that the department has a “culture of fear”. news has also been in contact with Peter Monrad-Hansen, who is a shop steward for the superiors in the department. He cannot comment on the matter, as all comments must be made via the communications department at the hospital. The management at the hospital has so far not responded to news’s criticism from the employees about a culture of fear. The commission interviewed a number of doctors at both hospitals who do not dare to report adverse events. “In interviews, several doctors said that there was no room to give feedback. They were afraid that this could cause problems for them later and thus experienced a form of culture of fear.” Jagge’s death was not reported as an unwanted incident Ukom’s task is to investigate serious incidents and conditions in the health and care service. Jagge’s relatives are among those who have registered concerns and notified the Norwegian Health Authority. Jagge’s medical history is thoroughly reviewed in the report. Despite the fact that Jagge, according to NPE, died of maltreatment, the case was neither reported internally nor notified to the authorities by the hospital. “The complications that affected the patient in our history were considered predictable and were never reported,” writes Ukom in the report. They also write that an injury with a hole in the intestine was not registered as an adverse event, despite the fact that it was believed to have been inflicted by a doctor. Nor does it appear in the record that the patient and his wife were informed of the injury. “The wife states that the man told her that he was sure that something had happened during the operation” This agrees with the opinion of Jagge’s closest relatives. Lawyer Tom Sørum Photo: Ingvil Øvretveit – There has been insufficient information during the treatment process about what went wrong, says the family’s lawyer Tom Sørum. – There has also been insufficient information after the death itself. It was only when Jagge died that it was written in the record what the next of kin had been informed about. “In our patient history, the information to the patient and next of kin failed,” the report states. Mandated to notify – but not notifying Healthcare personnel are required to notify of serious, unwanted incidents. Both at the gastrosurgery department at Ullevål and elsewhere, there are a number of examples of this not happening, according to the report. “Our findings may indicate that many adverse events are not reported or notified.” Many are afraid of their relationship with colleagues if they report. Ukom believes that the consequences of a lack of notification are serious. “The health service thus misses out on important learning and possible improvement, and there is a risk that the same incident could happen again.” Pål Iden, director of Ukom, the National Commission of Inquiry for the Health and Care Service. Photo: Arild Eskeland / news – It is under-reported when it comes to serious incidents in the health service, says director of Ukom Pål Iden to news. He will not confirm that it is the gastrosurgery department that the report is about, but does not deny that the patient they have written about is Finn Christian Jagge. And explains why they used this case. – We have entered into it precisely because it has not been caught by the hospital as an unwanted incident along the way. They use the Jagge case to ask an important question, explains Iden. – Why is it that we are unable to capture the serious complications, and use them both for learning and to correct the course along the way when things are about to go wrong? The Jagge family is grateful for the commission’s work. – Firstly, the family would like to thank the commission of inquiry for the important work they have done in this case in mapping and demonstrating that there is a deficient reporting culture within the healthcare system, says Tom Sørum. – They are sure that Finn Christian would also have been concerned that his tragic case could at least contribute to an improvement in patient safety and reporting culture at the hospital. Ullevål Hospital treats patients from all over the country. Photo: Lise Åserud / NTB The hospital will not comment news has tried to get an interview with Oslo University Hospital about the serious findings in the report, both related to Finn Christian Jagge and the general reporting culture at the gastrosurgery department at Ullevål. The hospital does not wish to comment on the case, because Jagge’s case has still not been fully processed by the Norwegian Health Authority. This is according to Hedda Holth, communications advisor at the Director’s staff at OUS. Jagge’s family has clear hopes for the Norwegian Health Authority’s handling of the case. – We believe, like NPE, that there has been a failure in the treatment of Jagge and that criticism should therefore be given, also from the Norwegian Health Authority’s side, says lawyer Sørum. From 2011 to September 2020, there were 33 serious deviations in the gastrosurgery department at Ullevål Hospital. Some have been notified by doctors. news already wrote about this in 2020.
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Culture of fear at the hospital ward where Finken died – news Norway – Overview of news from different parts of the country
