Alliance for Patient Safety

Amiad Taub:

Ok, First I would like to thank Knesset Member Elharar for bringing forth this discussion. This is not an obvious thing, and in my mind it’s the first and most important step taken in saving lives.

Approx. six years and one month ago, on 23 / January / 2011 Ofek went into an elective surgery with a smile on his face. He has not been smiling since. He came out of the surgery as a disabled person, requiring nursing care with 188% permanent disability. Following a whole week of cover up, after we were persistent in investigating the case, we have discovered that he was ventilated a number of times with CO2 instead of oxygen.

Eighteen months prior to this event, a similar event has occurred, a patient who entered to surgery was almost ventilated with carbon dioxide, and Dr. Yuval Maroz, a senior anesthesiologist, has noticed and saved him. On that same day he has sent a message to the entire Management of Hadassah Hospital with the headline – “We shall meet in the next catastrophe, cut off the valves so this shall not happen. Nothing has happened.

This was the last event in a chain of criminal negligence which included an operation performed in an adult operation theatre, an old ventilating machine, forgery of documents and cover up. Two weeks after the surgery, on 20 / Feb, the Hospital Director has reported to the Ministry of Health that Ofek has passed on. Here you can see three different versions of the same surgery. One from the day of the surgery that the surgery was successful, two weeks later it is updated that there were developments in the surgery, and they hope no damage has occurred, and the third report, issued already in February, almost a month after the surgery, where still no word was mentioned about ventilation with carbon dioxide.

To date, as of January 2017, there is still no word from Hadassah hospital about a patient who was ventilated with carbon dioxide. To date nothing has happened.

And I do not stand in front of you inventing things as Ofek’s father. There was a committee set forth by the Ministry of Health, headed by Prof. Katz, which has published its conclusions on 5 / Aug / 2013. I would like to briefly read to you five of its conclusions:

The directors have ignored Dr. Maroz’ warnings. The medical record was lacking and there was no mentioning of ventilating a child with ambo connected to CO2 instead of oxygen, even though they have found out about it even before the child was taken out of the operating room. The report to the family was conducted after a long delay. The committee views with severity the fact that nothing was changed for several months after the event in order to remove the CO2 valve. Please note, even with everything that happened they have not changed it for several months. The Hospital management has reported about the event in a faulty manner and much later, even though they had the exact information at hand at the time of the report.

Again – this is a report from the Ministry of Health. Not Ofek’s father and not Ofek’s mother. A report of the Ministry of Health, of a Committee you have appointed, an independent committee.

On 22 / Oct / 2013 Prof. Haim Hershko, the Public Ombudsman in the Ministry of Health has notified that he accepts the Committee’s report verbatim. It was in 2013. We are now in 2017. He notified that he will formulate recommendations about the personal responsibilities of the involved, and nothing has happened.

73 months have passed since Ofek’s tragedy and I am striving to understand how is it possible that the Ministry of Health ignores the forgery and cover ups which have turned a healthy baby to a vegetable. How is it that not a single person from the people responsible for this criminal negligence, of the guilty parties that even the State Prosecutor’s Office, though much later, has announced its intention to put them on criminal trial, were not suspended even for a moment and not even in order to examine the case. Just imagine how many children they have treated since. They did not even examine them for one moment.

I want to clarify, and I want it to be very clear, we are not against the healthcare system, we are not even against the physicians’ sector of the public, the physicians and the nurses are a wonderful sector which works from the bottom of their hearts and from the depth of their souls, and at times, under the worst conditions. We have come across many angels in our long and winding medical path. But this is not the story here. These are not angels, and we will fight these criminals, the one’s holding the MD title, who murder innocent children and their place is in prison cells and not in the operating theatres. We will fight these infected parts of the healthcare system, which instead of defending the patients are defending their friends, and assist them in covering things up for more than six years.

And this is not about making mistakes. Mistakes can happen. In the work of the physicians as well as anywhere else. Mistakes can happen everywhere. These are not mistakes. This is criminal negligence. This is a clear and blatant forgery. These are not innocent physicians, these are forceful and aggressive managers who are willing to do everything in order to defend themselves and their friends.

Ofek’s case is particularly shocking, and this is also our personal case, but it is only one link in a long chain of criminal negligence derived from hubris and battles of ego, of people who forgot their duty to the patient. The lives of the injured and their families will never go back on track, but these same criminals they continue working, receive wages, receive promotions and behave as if nothing happened. And the worst part is, they treat other patients daily. These patients treated by them today and have no idea what these individuals with inflated egos have done yesterday.

For us, to our greatest regret, this does not matter anymore, however, we have joined here together hundreds of the injured family members, to lead a battle which goal is to ensure that this does not happen to your children or to your parents.

This issue should be in a cross parties consensus: Jews and Arabs, right wing and left wing, children and adults alike. This is an issue which touches all of you. In my mind the legislative authority holds the responsibility to make sure that the operating authority does not become the covering up authority.

I am asking from Knesset Member Elharar that a discussion will be set today where the data from the last decade will be presented. How many examination committees were set by the Ministry of Health, how many physicians and staff members were suspended, how many physicians lost their license to practice. I believe there are only few. Out of 30,000 physicians, if we have only a few, this means they are covering up. I would like to know how many physicians and staff members were suspended, and I would like that the Ministry of Health explains what do they intend to do so that the justice systems will not grind to a halt, as they have been going on for six years with nothing to show for, and that they will stop with the lenient and compassionate attitude toward those who harm innocent people and patients.

In addition, I ask that a legislation or regulations will be promoted – it is not clear to me what is the correct pathway – to minimize the harm caused to future patients to the absolute minimum, to create a deterrence that will prevent harms to patients and prevent the torture caused by the law.

 The chairperson, Karin Elharar:

Thank you

Amiad Taub:

I would like to finish. I am doing just that. I would like to end with a topic that may be somewhat difficult, but this is the right way to end this. My son is a Jewish baby which was suffocated though he had done no wrong, and in my mind the most appropriate is to end my words here is by paraphrasing a protestation poem written by the human rights advocate in Nazi Germany, Martin Nimler. And so he wrote:

“I did not raise my voice when the Nazis took the communists, for I was not a communist; I did not raise my voice when they took the Jews, for I was not a Jew; and not when they took the members of the professional unions, for I was not a member in a professional union; and not when they took the Catholics, for I am a Protestant; and when they took me, there was no one left to raise his voice for me.”

So I am calling you to raise your voice in a shout. Not to be one of the covering up, nor the ignoring, nor the silent, because all of us and all of you, and all your parents, and your children, will go to a hospital one of these days. If you continue with discussing, with talking, with writing volumes upon volumes of multi – pages reports, which reach and achieve nothing, that your child or your father, your mother or grandmother – they are just the next people in line.

Thank you for your time.