The final findings of the forensic autopsy of the thirty-six-year-old ND, who died after being discharged from the Berane Clinical Hospital Center, confirmed that a perforation of the colon occurred during a colonoscopy, leading to inflammation of the peritoneum and sepsis.
The family states that the serious complication was not recognized while the patient was under the supervision of a doctor, although, according to the findings and medical rules, it was a process that lasted and gave clear symptoms. In a letter from the Dabetić family, submitted to "Vijesti", it is written that according to the autopsy findings, death occurred directly due to inflammation of the peritoneum, as a result of a perforation of the initial part of the large intestine during a colonoscopy.
"Although colonoscopy is often considered a routine procedure in practice, it is known in medicine that it carries certain risks, including perforation (puncture) of the intestine. For this reason, such complications require careful monitoring and timely response," the family says. The patient was under observation for several hours, but despite this, he was discharged home, and did not live to see the new day. The family points out that the final autopsy findings now indicate not only the cause of death, but also how the fatal complication occurred, and raises the question of whether the patient's condition was sufficiently monitored.
"The family expects the competent authorities, based on the final autopsy findings, to determine whether there was any negligence and who bears responsibility for the fatal outcome," the letter states.
The family also claims that it is particularly concerning that the doctors who participated in the treatment are still working, while to date no medical or disciplinary proceedings have been initiated, even though this is a fatal case.
The Ministry of Health did not respond to "Vijesti"'s questions regarding the three deaths that occurred in Bar, Nikšić and Berane at the end of the year.
From the department Vojislav Šimun Yesterday, they sent a press release, emphasizing that in all cases of adverse outcomes in healthcare, they "act in accordance with applicable legislation, through the implementation of extraordinary external controls of healthcare quality, the formation of committees composed of independent experts, as well as through professional supervision, inspection procedures and internal controls in healthcare institutions."
They said that in the case of ND's death, the family recently approached the Ministry of Health with a request to form an extraordinary external commission. They claim that KBC Berane has in the meantime conducted an extraordinary internal inspection of the quality of healthcare and informed the Ministry of Health of the findings, after which the procedure for forming an external commission in accordance with the law has begun.
"In the case of the death of a newborn at the Nikšić General Hospital, the Ministry of Health immediately formed an extraordinary external commission upon learning of the incident, conducted expert supervision and internal controls, after which a failure in the actions of the nursing staff was identified. In accordance with applicable regulations, the strictest measures were imposed on two employees - termination of employment." When it comes to the death of a nine-year-old boy from Bar, they claim that they requested reports from internal commissions, and simultaneously initiated inspection supervision, and disciplinary proceedings were conducted at the Bar General Hospital, after which the doctor was given a measure of conditional termination of employment. The formation of the extraordinary external commission, as announced, was conditioned on the completion of medical documentation, including the autopsy report.
The statement says that the Ministry of Health will not prejudge the outcomes of the proceedings or comment on their details while the prosecutorial and judicial processes are ongoing. They claim that they have initiated and are implementing systemic measures to reduce the risk of adverse outcomes, including the development of a national protocol for the early recognition and treatment of sepsis, an action plan for the prevention and control of intrahospital infections, standardization of vital parameter monitoring in high-risk patients, continuous training of healthcare workers, as well as increased supervision of private healthcare institutions.
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