Alliance for Patient Safety

בל"ה - ברית לבטיחות החולה

...All that is necessary for the triumph of evil
.is for good men to do nothing…                                                             
Edmund Burke                                                                                                  

Vered Shalev Horovitz – Excerpt of Protocol

Vered Horowitz:

It’s somewhat hard after Amiad and Rami to get back. I will focus on the cover up and what can be done with it. This was the case of my father, Eli Horowitz. There was an investigation committee, there was a control committee, there was an examination committee, the examination committee was set up and it did examine. Its conclusions were very harsh, I can repeat some of them, but they were published in public, so perhaps we should skip these in the one and a half minutes I have as my time. And that was it, the case was closed.

Three years later, and a long time after all the discussion in the matter have ended, the Ministry of Health deputy, Dr. Boaz Lev has wrote, in secret, an internal letter which has covered up on the entire thing, and now, this is a quote: “Department Internal Medicine F at Sheba is managed above and beyond. There is an agreement between all the bodies in the Office” – listen to this – “That there is no connection between the events that occurred on the same shift and the passing of Mr. Horowitz.”

Three years later, he turns the tables upside down, and without any explanation, a short letter which has reached our attention only due to a diligent reporter. I admit that I have seen the publication in a boasting made by Prof. Rothstein, but I thought to myself back then that this is just one of his superfluous boastings, and I was proven wrong. The reported has brought the letter written black on white.

So according to Lev, for example, everything that was done by the examination committee is completely erased. Everything said by Prof. Hershko, which position you are currently holding, it is also dismissed and in a few blunt words it was done, and the press caught it.

The Committee members – Prof. Hershko – so it was said by the Ministry of Health – did not see the entire picture, but Prof. Gamzo, who was the CEO back then, has told the reporters explicitly that he accepted Hershko’s conclusions. Meaning, he has explicitly accepted them. And Hershko on his part, has described courageously the pressures that were placed upon him to change his conclusion, and this is what he said: “There was one lawyer who demanded that I change my summary, and he did not receive that. We did not give in to the pressures placed by the lawyers, who work in a tireless war of attrition. I am not the address to turn to in order to write a second version to the things I wrote.” Perhaps he has found another address. This needs to be reviewed by the State Comptroller, I believe.

Except that Lev has acted independently, and without authority. He never opened the subject and a second committee was never appointed. The names of the doctors he consulted with were never published. And it was not for no reason that he forgot to mention to the family that he is investigating the case, since we were not supposed to know. And if it was not for Prof. Rothstein, which could not resist the matter and boasted about his achievements in the Sheba internal bulletin, and if it was not for the press who checked the matter with the Ministry of Health, we would not have known anything about this. This is the essence of cover up.

This must stop. It is unacceptable that the Ministry of Health will continue and investigate itself. They are not really doing it, and they cannot withstand the pressures place upon them. If we do not act to take away the auditing from the Ministry of Health, the cover up will continue, the public will be needlessly hazed in acts of trickery and the truth will never be revealed. Isn’t it what is happening now to all of us? They tell you about an examination committee, and you go on thinking that now they will reveal the truth, and oops, the tables are turned upside down.

Justice will not be done, lessons will not be learned and the things will happen again and again, and this is with an emphasis placed on not learning any lessons. It so happens that the Ministry of Health too, has an interest in taking this duty away from the Ministry of Health. The pressures will stop, and the Ministry of Health will be able to sit down and draw its lessons to be learned internally, and not just an external show off.

I will only say this now, I am calling the Ministry of Health to invest real efforts in drawing conclusions and learning lessons from their audits reports for the purpose of improvement of the care of patients, and in order for these type of events not to repeat themselves.

I am calling the State Comptroller to determine unequivocally that the Lev document is null and void, since my complaint, which was examined by a legally appointed audit committee, was just, was examined by a committee you have appointed same as the conclusions drawn by the Commissionaire Hershko, and therefore, this entire letter is illegal.

I am asking that the chairperson of the State Control Committee to move as fast as possible and promote legislation to remove the auditing body from the Ministry of Health to the benefit of the patients and the Office, the Ministry of Health by itself, in accordance with the recommendations of the State Comptroller’s Office. The State Comptroller has written its own recommendations in a clear manner in 2012 – Report no. 62. Read it. I can repeat them if you want, though I think it is not necessary. I suppose the State comptroller will say these things on its own, and it was repeated in 2015. It clarifies that the State Commissions, the committees and the examination of the physicians negligence – must be taken out of the Ministry of Health