Otwock. There was no intubation tube and the child died. The hospital responds to allegations after the inspection

In June, an 11-month-old girl was admitted to the pediatric ward of the Masovian Center for the Treatment of Lung Diseases and Tuberculosis in Otwock. The child was initially diagnosed with bronchitis, and the next diagnosis was pneumonia.

After spending a night in the hospital, the child's condition worsened and doctors decided to transport the little patient to a children's clinic in Warsaw.

While waiting for the ambulance to arrive, the girl stopped breathing. During resuscitation, the ward nurse called the emergency number for help. An emergency medical team was dispatched to the hospital because – according to our information – in the pediatric ward of a hospital specializing in the treatment of lung diseases and tuberculosis there was no infant-sized endotracheal tube.

According to our sources, during the attempt to restore vital functions, the child was not connected to the respirator and was ventilated manually (using a self-inflating bag). There was also no device used to monitor the ventilation of the little patient.

After 75 minutes, the rescue operation was interrupted and the doctor pronounced the child dead.

After our publication, a joint inspection at the Otwock hospital was carried out by the National Health Fund and the Patient Ombudsman.

“The conclusions after the inspection of the National Health Fund and the proceedings of the Monetary Policy Council are similar and confirm that There were a number of irregularities in the hospital that contributed to the death of an 11-month-old girl. The assessment of both independent proceedings is negative for the facility,” it was stated in the press release after the inspection.

Moreover, it was noted that “the lack of the required medical equipment in the hospital (intubation tube in a size intended for children) was a serious shortcoming, but the deteriorating health condition of the child after admission to the hospital and failure to undertake timely medical interventions adequate to the patient's conditioncontributed to the breakdown of the girl's health safety standard.

They also pointed out errors in organizing the girl's transport from the hospital in Otwock to the Warsaw clinic at Trojdena and the lack of tests that could have shown that “the child is developing respiratory and circulatory failure.”

A fine of PLN 390,000 was imposed on the hospital and recommendations were issued to “conduct training for medical staff in the field of resuscitation, verification and correction of procedures for transporting patients in life-threatening conditions, and urgent review of medical equipment.”

The prosecutor's office also started investigation proceedings. Hospital monitoring was secured, an autopsy of the child was ordered, an expert was appointed and medical documentation was secured.

As we found out, the investigation was transferred from the District Prosecutor's Office in Otwock to the Regional Prosecutor's Office in Warsaw.

Anna Kamińska, general director of the Masovian Center for the Treatment of Lung Diseases and Tuberculosis in Otwock, refutes the allegations of the National Health Fund and the Patient Ombudsman. She informed that the hospital had submitted “detailed reservations to the inspection protocol of the National Health Fund and the RPP”, and the position of the facility “was prepared on the basis of full medical documentation and taking into account the opinions of consultants and based on facts, not media reports”.

The CEO confirmed our findings about the lack of an intubation tube, saying that “the 3.5 tube (the size of the endotracheal tube for infants – ed.) has been replaced with a 16 Ch tube.” This parameter does not allow us to determine the type of tube, our information shows that it was simply a mammalian catheter.

According to director Kamińska, the use of other types of equipment “did not affect the ventilation process” and “the information that ventilation was not started due to lack of equipment is false.” The hospital director referred to the consultant conducting the inspection, who stated in the report that “based on the available documentation, it can be concluded that cardiopulmonary resuscitation was carried out in accordance with applicable standards.”

Kamińska also informed that “no other deficiencies in the equipment and supplies of the department were found during the inspections.” She also assured that the hospital has procedures for admitting a patient in an emergency, and that actions regarding the deceased 11-month-old girl “were carried out in accordance with the applicable procedure.”

The hospital also refutes the inspectors' accusation of errors in organizing the child's transport, explaining that when the girl's condition worsened, within a few minutes “a place of transfer was agreed” to the intensive care unit of a clinic in Warsaw. Let us remind you: the ambulance that was supposed to transport the child to another facility arrived after more than two hours, when resuscitation was already underway. “The problem with the arrival of the ambulance (transport – ed.) was not the hospital's fault,” said Anna Kamińska.

Further in the answer to our questions about irregularities, she stated that “in accordance with the organizational regulations and scope of responsibilities, medical staff are responsible for equipping the ward in accordance with the profile of services provided” and the procedure for transporting children to another hospital “was developed by medical staff and approved by the director for medical matters. The hospital representative also denied the allegations of the National Health Fund and the National Health Fund that no tests were carried out that would allow for the diagnosis of the child's progressive disease.

Finally, the director informed that an audit was carried out in the hospital, verification of applicable procedures, training was conducted, nurses were employed and post-audit recommendations were implemented.

The Mazovian Center for the Treatment of Lung Diseases and Tuberculosis in Otwock is supervised by the Masovian Voivodeship Government. Marta Milewska, the marshal's spokeswoman, announced that the hospital in Otwock “is subject to periodic comprehensive inspection (…), and once every six months (the management – ed.) it also sends reports on its substantive and financial activities.”

The last inspection was carried out in November 2022, but it concerned work on the reconstruction and expansion of Pavilion C – the one where the pediatric ward is located.

According to the information sent by the spokeswoman, a comprehensive inspection at the hospital took place previously – at the end of 2019. It concerned, among others, the analysis of the implementation of contracts with the National Health Fund, the average waiting time for specialist advice, compliance with patient rights, management of real estate owned by the hospital and the employment structure. One of the control points was also checking whether employees “wear ID badges containing their name, surname and function in a visible place.”

Marta Milewska assures that the office did not receive “signals of irregularities in the Otwock hospital in the provision of health care services.”

He also confirms that in September the marshal received explanations from the hospital management, which showed that the recommendations from the inspection of the National Health Fund and the RPP “have been almost completely implemented or are in the process of being implemented.”