Alliance for Patient Safety

Aviva Milgalter:

Shalom, I am Aviva; I am the widow of Dr. Eli Milgalter ZL, a cardiac surgeon that used to work at Hadassah. I am bringing here two examples, since my time is short, and they have answer a little on the question that is discussed here whether to take the commission out from the Ministry of Health. What is the connection between the commission and the hospitals, concerning the safety and concerning your questions, and whether anything was done? These are very relevant examples.

I shall tell them; on June 2011, at midday, six months after the miserable event of Ofek Taub; is this about the same physicians —; a baby of eighteen months is rushed to the Hadassah Emergency Room. 10 days earlier she underwent a heart surgery by the same surgeon as Ofek. My husband, Dr. Eli Milgalter, The Pediatric Cardiac Surgery Unit Director, is the emergency physician on – duty that day at Hadassah, and is present in the building. Nobody calls him, as is required in such a case. Instead, a wrong diagnosis was made for that baby and her condition began to deteriorate. It is noon. She arrived at noon. Only at 3 am, hours and hours after her hospitalization, and after some serious brain damage was already caused to her, Eli who is finally summoned, tries to save her life. At 3:55 am her heart stopped beating; that's what was written in the summary of her disease. When Eli arrived to the hospital at 3 am and saw her condition, enraged he asked the Pediatric Intensive Care Team "I am the physician on – duty, why was I not called in on time?" The answer he got was, "An instruction has been issued by the Department Director not to call you in such cases". The Department Director is the very same Department Director who is also accused in —; since then this issue has made him sleepless.

The Chairperson, Karin Elharar:

Madam, where does this information come from?

Aviva Milgalter:

It is my husband. I shall define what the essence is — and then you could know how —

The Chairperson, Karin Elharar:

Yes.

Aviva Milgalter:

My husband worked for 37 years at Hadassah; an excellent physician; since 2008 in the same department we are talking about here. There were some serious failures; he was warning about them and what he got in return was harassment, and at the end he died of cardiac arrest. I will only be giving you two examples; these are examples of proven information, with documentation, and some of them are known to the Ministry of Health, the representative from Hadassah knows about them as well as many other people. Everything is accurate, including the hours and including the —

So, we are at night. When he arrives he asks why they didn't call him earlier. They say that an instruction was issued. Since that night he has been sleepless. "Had they called me, I would have diagnosed the tamponade." The fact that Eli could have done this, is well known; everyone that is acquainted with him knows that he would have diagnosed it right away, take the baby already at noon to the operating room, and it is reasonable to assume that she would been alive today. He requested the Legal Department of Hadassah to investigate the case; however the issue has been silenced. I am already arriving to the Ministry of Health and you will draw your own conclusions.

Now I shall demonstrate to you the cover-up method; how it is done on the ground. One year after the  case, one year, Prof. Hershko, the Public Complaints Ombudsman in the Ministry of Health, issues summons, on which Dr. Lev is also signatory, for an investigation committee on the issue of the baby's death. Eli is excluded from the committee. After that a letter is issued by the legal councilor of Hadassah which assigned physicians to the committee. Eli is not assigned and he requests to be assigned. Eli is not getting any invitation. The hospital and the Ministry of Health imposed confidentiality on the affair and by doing so took Eli completely out of the picture. Later on it turned out, and here we arrive at the cover – up, that the committee was never convened in the Ministry of Health and at the end a summary report by the Ministry of Health was written which was based on an internal report of Hadassah. I am certain that it is not written there that they did not call the on – duty physician. The Ministry of Health acted hand in hand with the hospital's management to conceal the case from the public eye and to conceal the negligent fact that the senior physician on – duty had not been called to the Emergency Room. The parents of the baby don't know and will never know what really killed their baby and everything under cover and the cloak of medical confidentiality.

It is one case out of tens of horrifying cases upon which Dr. Milgalter, Eli, my husband warned and the system covered-up. I have a list of them, if someone wants. Eli had alerted on similar cases already in 2009. He wrote a document, backed-up by proofs about putting patients at risk and sent it to Hadassah Management and to all the departments managers. The heading read "Improper management can kill patients". The document was received with total disregard, a matter known as self – willing blindness.

Another small example which is being clarified these days and I have spoken on this with the Hadassah representatives. In that document Eli warned about a heart – lung machine. In 2009 he is warning about a heart – lung machine called Claude System, the use of which is dangerous. Again they ignore it. Since then and until today additional seven mishaps have occurred with the machine. Recently, another senior physician cautioned the hospital management and demanded to stop the use of the machine until its safety is verified. Dr. Lev and the people of the Ministry of Health received that warning. Hadassah received that warning; nonetheless Hadassah established an internal investigation committee headed by Prof. Arthur Polack at the present, Eli warned about it in 2009, but the use of the machine continued. And again the hospital is implementing the same tactics. The physician that warned is threatened with being fired. I cannot mention his name, but people who know, know about this.

At the present, as we are sitting here and showing presentations and talk, it could be that at this very moment, because today is surgery day at Hadassah as I well know, they might be using the same machine and possibly endangering patients yet again and maybe in a year from now they will convene and discuss the machine. You could argue and that may be your answer, that you are not sure whether the machine is safe or not, and it is possible that it is safe; but don’t we need to check first and only then try it on the patients.

Eli worked in Hadassah for 37 years and saw it as his home. He was a surgeon, and senior, a specialist for children and adults alike, who won awards and appreciation and due to his work and contribution Hadassah was a candidate for the Nobel Peace prize. However since 2008 Eli's life changed and become a nightmare. From an very appreciated cardiac surgeon he becomes a pariah, compartmentalized and an enemy of the system. Why? Because he was warning them; Eli continued and warned about severe failures committed in his department and the system continued and abused him for seven long years. The professional and personal campaign against Eli was done in a special method of abuse, which is unique to the medical profession; the method is called "sham peer review", not shem, sham, and in Hebrew it is known as “phony colleagues' critic”. It is very good tactics.  It is a sophisticated and wicked method at the same time, which obstructs the alerting physician's work and is used by the hospitals to neutralize and remove the alerting physician, while providing full protection to the aggressors. Until today there is full protection to the aggressors, including aggressors against children and adults alike.

The saga of abuse was sealed with his sudden death; on 6^th of May, 2015 Eli passed away from cardiac arrest. That's the reason I am here, in his shoes, talking in front of you. I am shouting instead of him, my husband, which for years warned about omissions, negligence and crimes.

I am joining the demand to establish an independent auditing body which will be the address to turn to for patients injured by medical negligence, and in parallel, and here I join the Knesset member, will provide protection to physicians who expose the injustices and corruptions. This body will force managers and physicians to report in real time about the omissions and negligence and will impose sanctions on the management not acting accordingly. In regards to Eli, he was the one warning and he was punished for it.

I shall finish with a little quotation of Prof. Meir Brezis, former Quality and Clinical Safety Center Director at Hadassah, who together with Eitan Meiri, an expert on managerial bullying, because that what has happened in the case of Eli, recommended Eli after his death for the Medical badge of  "Ometz." "We believe that awarding the badge to Dr. Milgalter ZL will be a wake – up call to the medical institutions in Israel; to monitor, to destroy completely harassments and harmful behaviors which are endangering patients' lives, which are harming safety treatment and risking the physical and mental health of our best physicians. Thus the tragic loss of his life will contribute to saving many. By that "Ometz" will contribute to the continuation of his courageous legacy and his death will not be in vain."

Just one more sentence I want to say, and it is important. On the morning of Ofek's surgery, during the morning meeting, Eli warned that room 8 is a dangerous room for operating children; the infrastructure is not built for children's surgery. Nobody has listened to him back then. Incidentally, ignoring such a physician, a specialist, is part of the abuse, and when it concerns the medical system patients —

Yael German (Yesh Atid):

Now also there is a physician in Hadassah who is warning not to move children to the adults’ Hemato-Oncology Department and nobody is paying any attention to him.

Aviva Milgalter:

Right, right.

Call:

But this data is totally incorrect.

The Chairperson, Karin Elharar:

No, we are not managing this.

Call:

Totally incorrect.

Aviva Milgalter:

Just give me another sentence, I am finishing my words; just one sentence which is connected to the discussion. He also warned on the day of Ofek's surgery and also warned the surgeon, but another thing. He did not receive an invitation to the Ministry of Health committee. They have tried to prevent him from testifying in the committee, however at the end he testified. But when I saw the report I don't see that his testimony appears there.