At the weekend, news was able to tell the story of Sigrun K. Marcussen. She was a 50-year-old woman who died at Oslo University Hospital (OUS) last spring. By then she had received three livers in 13 days. The first liver was a fatty liver, which she should not have received – something OUS acknowledges. The next two transplants were considered necessary for her to have a chance of survival. But her state of health was so serious that she was treated further in the intensive care unit, where she died. The death occurred after complications with a breathing tube in the intensive care unit, and was routinely reported to the Norwegian Health Authority. They concluded that the health care provided was not unreasonable. – How could this happen? But the assessments that were made at the Transplantation Surgery Section, and the reason why Sigrun was admitted to the intensive care unit, were not reported to the Norwegian Health Authority. It was only reported in the hospital’s own deviation system. Last year, the Norwegian Health Authority therefore did not investigate the work or the routines of the section at OUS in this case, which is the only place in Norway that carries out this type of operation. – It is not good enough, says Ingve Marcussen, Sigrun’s widower. He believes that the death has not been sufficiently disclosed, and has therefore reported the case to the Norwegian Health Authority again for a new assessment. – I cannot understand how this could happen in such a hospital. The need for the breathing tube was not vital, and the need for a new liver was not urgent, says Ingve. OUS apologizes Section chief, Morten Hagness, says the case was not reported because the outcome was not unexpected in relation to the foreseeable risk. Photo: Håvard Greger Hagen / news Section chief, Morten Hagness, at the Transplantation Surgery Section, apologizes for the strain the family has been exposed to. He says that the hospital has full responsibility for all the treatment and assessments that were carried out during the process. – With the results in hand, it is quite clear that the first transplant should not have been carried out, but the assessments along the way indicated that this would go well, says Hagness. He does not want to go into the details of what went wrong when Sigrun received the first liver, as long as the case is under consideration by the Norwegian Health Authority. – But we have raised the incident in the department’s regular complication meetings and had our own hour-long meeting about this matter, says Hagness. From what news understands, the section has changed its routines after the incident. – Why was the case not reported to the Norwegian Health Authority? – We did not report the case because it did not meet the criteria for further reporting. This means that the outcome was not unexpected in relation to the foreseeable risk, says Hagness. – What do you think about the fact that the bereaved have reported this to the Norwegian Health Authority? – We take note of that, and it is their full right to do so. If the Norwegian Health Authority thinks we should have reported it, we will learn from it. Ingve and Sigrun had been together for nearly 30 years, and planned for a long life together despite Sigrun’s health challenges. Photo: Privat Increasing number of cases Legal director of the Norwegian Health Authority Anders Haugland says on a general basis that reporting serious incidents is important as part of a larger process. He further says that it is no longer unusual for relatives to report to the Norwegian Health Authority. – It is an arrangement that was legislated in 2019, and there has been an increasing number of messages as it has become better known. It does not necessarily mean that there are more incidents, but that there are more people who think that this is an opportunity that they want to make use of. Legal director of the Norwegian Health Authority, Anders Haugland, says relatives were given a statutory right to report cases in 2019. Photo: Terje Haugnes / news – Poor reporting culture Last spring, the National Commission for Health and Care Services (Ukom) focused its attention on unwanted incidents in hospitals . They submitted a report on how the incidents are captured and how the authorities are possibly notified. The background for the report was several messages of concern from both relatives and healthcare personnel that unwanted incidents are not always reported or notified. – The reporting culture is better than before, but it is still far too bad, says Olav Røise. The former chairman of the board of the Norwegian Patient Association and the professor says that the regulations for reporting incidents to the Norwegian Health Authority are initially very clear. Professor emeritus Olav Røise believes that the threshold for reporting serious incidents to the Norwegian Health Authority in hospitals should generally be too high. Photo: Private – In the case of death, there is no doubt, but in the case of serious incidents, it is highly unclear, says Røise. Calls for transparency He points out that in the case of such incidents, the regulation introduces the concept of “foreseeable risk” – what is an expected risk in the event of unwanted incidents. – This opens the door for assessments among the professional community, and very different views can arise on what is a foreseeable risk for the same type of incident, says Røise. On a general basis, he believes that you are better at reporting cases in what he refers to as “forward-leaning environments”. – In environments where you are a little more reserved, and where you are concerned about looking after collegiality, this is demanding, he says. – Why is it important to report cases to the Norwegian Health Authority? – When you are unsure whether an incident is something to be expected, but which is serious, you should report it. Because it provides openness and seriousness, and gives relatives and patients confidence in the healthcare system. – Should the liver transplant mentioned in this case have been reported to the Norwegian Health Authority? – Yes, definitely, firstly because this is an unexpected and serious incident which, in my opinion, should be reported. – It is clearly within the threshold for what must be notified. In addition, it is difficult to claim that it is foreseeable because those in the department have subsequently acknowledged that they are changing procedures as a result of it. Hello! Do you have any input? Hi. Do you have something on your mind after reading this case, or do you know of other matters we should investigate? Feel free to contact us by e-mail in the first instance. It is also possible to send tips and information encrypted and secure via news’s extra secure notification reception – see how to submit via news’s SecureDrop here.
ttn-69
Got three livers in 13 days – relatives reported themselves to the Norwegian Health Authority – news Norway – Overview of news from different parts of the country
