How could a 55-year-old woman, brought by firefighters to the emergency department of Lariboisière Hospital, Paris, for headaches, during the night of December 17 to 18, 2018, have escaped the vigilance of caregivers and be found dead in the waiting area of this service nearly twelve hours after admission without having been examined by a doctor?
To explain this failure in the support, "There is no individual fault of a carer, but a series of malfunctions that have not stopped the process leading to the tragedy", ensures World Professor Dominique Pateron, President of the Collegiate of Emergencies of the Public Assistance-Hospitals of Paris (AP-HP), at the end of his fact-finding mission. Asked by the management of the hospital group and the regional health agency of Ile-de-France, this report, published Monday, January 14, does not address the causes of death – unknown to date – but to " process " and to "Organizations" emergencies of Lariboisière.
On December 17, the patient was brought by the fire brigade at 6:17 pm, registered at the emergency room at 6:40 pm, then placed on a stretcher in the waiting room of the so-called "short" circuit, where the majority of people go for treatment. A nurse sees her at 7 pm and 9 pm But when around midnight a nurse's aide calls her four times – once in front of the emergency room – so that she can finally be examined by a doctor, more than five hours after admission, she does not answer.
"Monitoring not compliant"
At 23:55, she is marked as " born not answering the call » and 1:18, it is declared "Running away", that is, deleted from the lists. And it is only at 6 o'clock in the morning that a caregiver, discovering her lifeless on her stretcher, alerts her colleagues and makes the transfer in the emergency room vital. The death is observed after ten minutes of resuscitation maneuvers.
"Patient monitoring did not comply with internal procedures", says the report. For example, the patient had to be seen at least twice between 21:00 and 01:18, the time she was declared "on the run". And before deleting the lists, it would have been necessary to systematically check all the bracelets of the patients present in the surveillance zones, as provided by the protocol set up after the death in February 2014 under similar conditions of a 61-year-old woman. emergency room at the Cochin hospital in Paris.
"Given the extremely difficult conditions that night, it was not possible", recognizes Professor Pateron. At the time the patient is called, around midnight, about forty patients are in the waiting area of the short circuit, including ten on stretchers. During the day of December 17, "The activity was very strong" in the largest emergency service of the AP-HP, with 249 recorded passages, against 230 on average.
Phenomenon of "funnel"
"The malfunctions are due in particular to the high attendance, the ability of the service to function properly were exceeded that night", says Dominique Pateron. The presence of the paramedical staff was "In accordance with the estimated schedule" of the service and the general rules of organization concerning the sorting and operation of the service examination areas were "Respected" is it noted in the report.
More structural problems are put forward. For example, the "medical staff to activity ratio" at the Lariboisière emergency department is lower than other AP-HP emergencies: with 23.5 doctors where it would take 28 to reach the group average. .
There would also be a " global problem of surface insufficiency » and number of exam box. Which leads, according to the fact-finding mission, "Most evenings at a funnel phenomenon" and "A significant number of patients waiting for a medical examination". Result: this area, which is found, by the geographical location of the hospital, to accommodate "Many precarious people in distress with or without pathology", is "Often saturated and insufficiently supervised".
The management of the AP-HP announced Monday a battery of measures to improve the organization of emergencies Lariboisière. Reinforcements of medical and paramedical staff are scheduled, a caregiver is already assigned since 2 January to monitor patients in the waiting room of the short circuit. All medical and medical staff will also be "trained or reformed" in the next two months to the procedures of identity-vigilance.