Alliance for Patient Safety

Vered Shalev Hurvitz:

First of all, on this issue; and what if you will have the power?! Indeed you have done the act — in the case of my father, indeed for this exactly and this topic, we are going to talk about. You really did it, two years after the file has been closed you wrote an acquittal letter to Prof. Rothstein in order to acquit him from everything that had happened earlier. You didn't receive the power to do that, and then today actually you are asking for the power —

Boaz Lev:

The answer is not correct. Not correct. Also there was —

Vered Shalev Horowitz:

Just a moment; what is not correct?

Boaz Lev:

If we are opening it here, it is an event that simply, it is not correct, and the file hasn't been closed until the day the letter was written which regrettably —

Vered Shalev Horowitz:

Sorry, I received a letter —

Boaz Lev:

That regrettably was not sent to you. I apologize; I think that the ruling was correct, complete.

Vered Shalev Horowitz:

Not true. I received —

Boaz Lev:

And I think that he received good treatment. I am sorry about that he passed away. He received good treatment.

Vered Shalev Horowitz:

Sorry, two and half years before, three years —

Boaz Lev:

Not on others, but —

Vered Shalev Horowitz:

I am very sorry, and then I am asking the right for my two minutes.

Bezalel Smotrich (Habait Hayehudi):

As a Ombudsman he also has the right to acquit. It is impossible to complain about him. If he examined the entire investigation and did everything and came to the conclusion that it had been in order, it is impossible to come and complain about it.

The Chairperson, Karin Elharar:

Vered Shalev Horowitz.

Vered Shalev Horowitz:

I want my two minutes.

The Chairperson, Karin Elharar:

You will get the two full minutes; I just want to say the following, to you and all that are sitting around the room. Again, I am really imploring at this stage, don't let us enter into the medical files —

Vered Shalev Horowitz:

I did not speak about a medical file. I spoke about a procedure that the State Comptroller has attested to it —

The Chairperson, Karin Elharar:

Fine, ok; one moment, Mrs. Vered Shalev Horowitz. This was my first remark. My second remark, I'll say something that might be unpleasant to hear in this room, but it is an option; it could be sometimes that in the view of the receiver, the answer is not appropriate and incorrect, but there is an option that the file will be closed because it has been investigated and —

Bezalel Smotrich (Habait Hayehudi):

That there was no negligence;

Vered Shalev Horowitz:

But three years before; He had opened it three years later.

Boaz Lev:

It was not opened by me.

Vered Shalev Horowitz:

You didn't open it; it is correct; He did not open it; he only wrote a letter addressed to Prof. Afek, who was the Manager General of the Ministry of Health.

Boaz Lev:

No, it is definitely not —

Vered Shalev Horowitz:

I will say the things I wish to say, and let me finish my words to the end. The conflict of interests is clear, since Rothstein was the Deputy General Manager at that period in time; he wrote it three years later after the case was closed — the case was closed by Prof. Hershko —

Boaz Lev:

The answer is, not true.

Vered Shalev Horowitz:

One moment; on 19 / July / 2012 I have received a notice about the closure of the file. What has happened is —

Boaz Lev:

Not true. No. The committee had finished its work and it was the beginning of the clarification, with all due respect.

Vered Shalev Horowitz:

By no means; by no means; not at the beginning of the clarification; I am in shock. I am in shock from these facts.

The Chairperson, Karin Elharar:

Mrs. Vered Shalev Horowitz, in principle;

Vered Shalev Horowitz:

Totally in principle; I want to talk about it. I want to repeat some sentences that were said exactly at the closure of this file. "The medical team did not prepare properly; did not evaluate correctly the severity of the situation from the beginning; consequently no warnings were passed on to the persons on duty; no effort was made to monitor the condition of the patient; the family was not updated about the severity of the patient’s condition. Not less severe is the fact that the Ward Manager was not updated about the deteriorating situation of the deceased, even though he was present at the department. The event exposes a significant weakness in two planes"; listen to the procedures, how you learn. "First of all, failure in transfer of essential information; second point, lack of a responsible overlapping method". Will you not agree with me that this is an elementary matter in the department? The team should have approached the senior physician directly, in this case to the Ward Manager who was present on the ground, for six hours, or even eight hours he was present right there; on the other hand, the obligatory responsibility of the physician on duty, that is, the Ward Manager in this case, is to be updated about what is happening in his department on his initiative and not leave it to the decision of the on duty physician. It's not me that said that; these are the conclusions of the previous Ombudsman, the one before you. This is a quote from Hershko’s conclusions.

The Chairperson, Karin Elharar:

I am trying to move this discussion to the principle lanes.

Vered Shalev Horowitz:

Exactly what I am doing; three years later we hear about exactly the same department, from Dr. Lev, a totally independent letter, his alone, and he can say that not, intended for Prof. Afek. I have it. It is attached to you as well. "Internal department F in Sheba is managed exceptionally well". Listen carefully, on exactly the same department "there is consensus among all the bodies in the Office that there is no connection between the events and the death of Mr. Horowitz".

The Chairperson, Karin Elharar:

Moment, Vered; let's translate this to the principle issue.

Vered Shalev Horowitz:

That is exactly what I am doing.

The Chairperson, Karin Elharar:

What is the complaint in principle?

Vered Shalev Horowitz:

That is, to this entire story there is no connection and to all these there is no connection between the death and between t — between everything that had been done over there. It is important that it should be clear. A department without a blemish to its conduct, as Dr. Lev says here. There is no correction, no learning here. No one will move backwards. Indeed, what was the story? How was it discovered? That Prof. Rothstein boasted about this magnificent department; then there is no correction, and forget about it; there will be no correction. A failure covered – up will not be corrected and they could not tell me otherwise.

The Chairperson, Karin Elharar:

No, fine. I am only asking.

Vered Shalev Horowitz:

And in this case also, he really not —

The Chairperson, Karin Elharar:

I want to ask a question.

Vered Shalev Horowitz:

One thing only and I will be finishing. Concerning the arguments; I want to tell you, Seneca was wiser than us and said "to err once is human, repeating the mistake it is already from the devil". In translation to modern times and not the Roman era, it is criminal. A second time is already criminal. With all the learning, I am simply telling you; not in the hands of the Ministry of Health, and it is not personally against you; by chance it was you who wrote this letter. I still don't know its origin, from where it came —

Boaz Lev:

I have proposed to you few times to meet in order to explain it to you.

Vered Shalev Horowitz:

You proposed to me retroactively after it had been revealed to the reporter. Definitely you did not write anything to me.

Boaz Lev:

The truth is that I didn't know that it did not reach you.

Vered Shalev Horowitz:

Just a moment; but I say that it must not be agreed that the Ministry of Health is the one t — they let the cat guard the milk; out of one simple reason, and that's why I am here. You can say that there is another path, criminal; I personally did not choose the criminal path; I have not enough strength. It takes seven years in the criminal path. The fastest path for correction is this civil path of the Public Complaints Ombudsman, but I encountered — and fine, a committee has been set up and everything was done in order, only the three years that followed were not right; then, suddenly a letter is written which was not supposed to reach my hands, which simply erases everything that the investigation committee had done prior to that.

The Chairperson, Karin Elharar:

What I am trying to clarify —

Vered Shalev Horowitz:

What I am saying that it cannot happen anymore.

The Chairperson, Karin Elharar:

What you say, in principle, is that you received two documents; one document saying, there was a problem; after three years had passed you received another document —

Yael German (Yesh Atid):

She didn't receive it.

Vered Shalev Horowitz:

No, I didn't receive anything. One day I received a phone call from Meital Yas'ur that asked me "Do you know that there is an acquittal letter?" the investigation committee and its results were made public in all the papers; certainly all of you have read it; all the failures that I have enumerated earlier; it is not what I have said. It is the decision of Prof. Hershko, the Public Complaints Ombudsman.

The Chairperson, Karin Elharar:

Ok, then according to your argument, to your request —

Vered Shalev Horowitz:

That's a fact that if you, the Deputy Manager General write it, Manager the General signs.

The Chairperson, Karin Elharar:

Vered Shalev Horowitz, your request is to take the Ombudsman out of the Ministry of Health?

Vered Shalev Horowitz:

Absolutely positive;

The Chairperson, Karin Elharar:

Ok.

Vered Shalev Horowitz:

Because it is not worthy — this conclusion simply is not worth the paper it was written on if it can be revoked after three years.

Dan Bental:

The State Comptroller also commented on this phase between the finalization of the conclusions of the investigating committee, which sits three, five years; I don't know, now the time tables are reduced, between the final ruling that is issued by the Manager General, from the Deputy Manager General. There is some very strange process there which was not pointed —

Boaz Lev:

I must reply briefly.

The Chairperson, Karin Elharar:

You will respond.

Dan Bental:

We had few discussions with Prof. Gamzu about it. We were promised that it is going to be regularized and there is going to be an orderly procedure. Until today we have not received it.

Boaz Lev:

Well, am really sorry for the event. I apologize that the letter did not reach you. I must say it like this; since the finalization of the committee, which in fact was a committee that examined the data, not all the matters were brought forth in front of it. Following the same, there were responses of the defendants. Following that, there were quite a few discussions which were finalized only when this letter was issued; this one, again, to my regret did not reach the Horowitz family. I really apologize, I regret that this happened in this manner. I am not ashamed of this decision. I think that the department treated him well; it is not clear to us — but pity — that is to say, that's not the point.

Amiad Taub:

But it is good that there is nice connection with the families.

Vered Shalev Horowitz:

If so, in 2015 he wrote the letter —

Amiad Taub:

They are talking about excellent connection with the families.

Boaz Lev:

Incidentally, I must say —

Vered Shalev Horowitz:

In 2015, four years, he wrote the letter, then 7 months?

Boaz Lev:

I don't want to open here the discussion about the event, this is not appropriate.

The Chairperson, Karin Elharar:

I am really asking not to go back to the individual cases.

Bezalel Smotrich (Habait Hayehudi):

What do you, the State Comptroller representatives, say about this dilemma? Certainly if it was taken out, it will be more objective; conflict of interests etc. On the other hand, the advantage of the familiarity and capability to handle immediately, and then, the ability to translate it into action is lost. It has a disadvantage here.

Dan Bental:

In the report we unequivocally have recommended to take it out —

Bezalel Smotrich (Habait Hayehudi):

But I am asking you how do you cope with the argument about the difficulty it creates to the capability to immediately translate it t —

Yael German (Yesh Atid):

It should be two parallel processes between which there is no connection.

Call:

Incidentally, that's the way it works in the army.

Yael German (Yesh Atid):

See what they are doing in the air force.

Call:

Yael, in the army it is two parallel processes.

Bezalel Smotrich (Habait Hayehudi):

In the air force the debriefing is internal; the commander is conducting the debriefing.

Yael German (Yesh Atid):

But without any connection; if it is rightly found that indeed there was a violation, then they put on trial.

Bezalel Smotrich (Habait Hayehudi):

But we did not speak now about putting on trial; you want the auditing —

Yael German (Yesh Atid):

The evidence is not used — no, you are confusing —

Bezalel Smotrich (Habait Hayehudi):

No Yael, you didn't understand the question I have asked.

Yael German (Yesh Atid):

There is debriefing; the initial debriefing is not used against.

Bezalel Smotrich (Habait Hayehudi):

Where does the initial debriefing take place? Where does it take place in the army? Within the unit, not by an external body.

Yael German (Yesh Atid):

Mostly by the military police;

Bezalel Smotrich (Habait Hayehudi):

What are you talking about? The debriefing is conducted within the unit. The direct commander is conducting it, and after that the battalion commander's debriefing, regiment commander debriefing.

Yael German (Yesh Atid):

No, I am speaking in parallel.

Bezalel Smotrich (Habait Hayehudi):

But we are talking now about the debriefing. This body is in fact similar to debriefing.

Yael German (Yesh Atid):

I have a little experience —

The Chairperson, Karin Elharar:

Knesset members, we are not discussing the army now.

Yael German (Yesh Atid):

If you want, I shall talk to you later. I have very rich personal experience with debriefings in the army of training accidents. Very rich, and it is two parallel matters.

Bezalel Smotrich (Habait Hayehudi):

But it is not the discussion.