The short version
- Selma Jensen (66) died of a heart attack two hours after she returned home from the medical center without receiving medical supervision.
- The state administrator points out violations of the legislation and a lack of good investigation routines.
- Selma’s family believes that women’s heart problems are under-communicated and is considering a lawsuit against Harstad municipality.
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Selma should have been assessed by a doctor, believes the State Administrator in Troms and Finnmark.
“Our assessment is that the failure in treatment unfortunately led to the patient’s death,” writes Norwegian Patient Injury Compensation (NPE).
It is Harstad municipality that runs the medical center Selma Jensen visited. Municipal director Børge Toft apologizes for the incident.
– After the tragic outcome, we have gone through routines and practices, and we are continuously working on quality improvement in our doctors’ offices as well. This includes measures to prevent something like this from happening again, he says.
It has been over a year since the incident. Selma Jensen and her husband Ole Martin Bergan celebrated Mother’s Day and birthday at home in Harstad together with Selma’s son and grandson. Selma had for a long time complained of stomach problems with vomiting, nausea, bloating and acid reflux. During the coffee, she hides in the bathroom. She does not want the grandchildren to experience a grandmother who is so unwell on a day that should shine with joy and energy.
Recently, she had been to the doctor for examination and treatment refluxReflux disease is symptoms and signs that acid and other contents from the stomach come up into the esophagus. Reflux disease is one of the most frequent complaints from the digestive tract.. It didn’t get better, and some nights she slept in the chair because lying horizontally prevented her from breathing.
Ole Martin had asked her if she shouldn’t be investigated for something other than reflux. The walks were almost over. She was short of breath and told her husband about tightness in her chest.
– She said that the doctors thought it was inflammation of the oesophagus, and she agreed with that, says Ole Martin.
On Mother’s Day, he asks if he will drive her to the emergency room. She thinks it will go well. The next day she has an appointment with the GP.
At the doctor
The doctor’s appointment results in an increased dose of anti-reflux medicine. According to the family, the substitute doctor suggests a referral for a new examination and will discuss it with her GP. If she does not get better within two days, she should get in touch. On the phone to her son Tommy Sørensen, she says that she feels well taken care of and is happy about a new examination since her health condition is only getting worse.
The morning two days after the doctor’s visit, the condition worsened.
Ole Martin went to work at seven o’clock. The two had agreed that she would drive a relative to the dentist a couple of hours later. It did not work. When Ole Martin called to ask if she was ready to drive, she was still in bed.
– She had to go to the doctor for an immediate help appointment. I helped her out of bed, into the car and up to the medical centre, he says.
There is a queue in front of the counter. Selma can’t bear to stand. She has to sit down, while Ole Martin stands up. When he approaches the hatch, she gets to her feet and the two switch places.
She asks for an immediate help-hour (ø-hour). Selma, who had been there two days earlier, says that the reflux has worsened and that she had pain after eating, says her husband. She will be put on the first available island appointment the medical center has. There is a three hour wait. According to the family, no doctor comes to ensure the quality of the decision.
– She couldn’t sit there and wait, as scrappy as she was. We agreed to drive home in the meantime, says Ole Martin.
In the car, the wife says that she feels a little better. She gets a place in the stress reliever in front of the TV. The two agree that it is okay for him to take a trip down to work with leftover cake after the Mother’s Day celebration, before they have to drive to the medical center again.
The heart
Just before twelve o’clock, Ole Martin is back. He finds Selma on the floor in front of the chair. CPR does not help. When the ambulance arrives with a defibrillator, there is no response either.
The autopsy report concludes that the circumstances surrounding the death are consistent with a recent heart attack. In addition, supplementary examinations of the heart show that smaller areas of muscle fibers have been replaced by cell-poor connective tissue that can match older, healed small infarcts.
In a terraced house in Asker, Tommy Sørensen is looking through the papers about his mother’s death. Selma’s youngest son was in Eastern Norway when she suddenly died a year ago.
– We used to talk every day. I always called her from the car on the way to work. That is why I knew so much about how she experienced her health condition.
He concentrates not to burst into tears. They did not come until he visited her grave a year after her death. Before that time, the mind has shadowed the deep longing.
The son wishes so fervently that others will not have to experience the same. That one’s loved ones do not have to die because, according to him, the routines in the healthcare system are too bad. And because women’s health challenges are not taken seriously.
– This had never happened to me as a man, says Tommy Sørensen.
– That symptoms of heart failure are not taken seriously. In her medical record, it says that she has heart problems in the family. Doctors should know that women often have different and more diffuse heart attack symptoms than men and that digestive problems are one of them.
Supervisory case
A month after the death, Tommy Sørensen, on behalf of the family, submitted a notification about the incident to the Norwegian Health Authority. They again asked the State Administrator in Troms and Finnmark to set up a supervisory case. They were to assess whether the patient received proper health care in connection with the treatment of the stomach pain and possible reflux symptoms. Half a year later, the conclusion comes from the appeal body:
The medical center in Harstad municipality did not provide the patient with proper health care in connection with the investigation/treatment of a deteriorating health condition.
“There is a breach of the Health and Care Services Act section 4-1”, it says.
It is Harstad Tidende that reports on the case first.
In the assessment, the State Administrator points out that the patient’s complaints and symptoms could be compatible with a worsening of the reflux symptoms, but that, according to the journal note, an alternative diagnosis was not considered either. “The ECG was not taken and possible heart symptoms were not assessed either,” writes the State Administrator.
The assessment is that a clinical examination should have been carried out with, among other things palpationPalpation is a medical-diagnostic examination in which the examiner’s sense of touch in the fingertips is used, and the patient’s possible indication of pain during the examination. Palpation can be done with one or two hands and can be divided into superficial and deep palpation. of abdomen/intermediate floor.
In the supervisory case, they also take into account that it can be difficult to prioritize who should receive health care when you sit and receive patients at a medical centre. But there “should be routines for proper clinical assessment of patients who, upon re-contact, convey a worsening of their condition”, they write.
In a summary of the case, they are clear about why they believe it is an offence.
“The patient at the last inquiry should have been assessed by a doctor to clarify any need for immediate help. The business should have routines which ensure that the doctor’s office is able to pick up changes in the patient who sees a doctor again.’
The state administrator also considers that Harstad municipality should have notified the Norwegian Health Authority about the serious incident.
Routines
Municipal director Børge Toft in Harstad says that the municipality will review routines and practices in the case of death.
– What do you do specifically?
– Among other things, there have been initial talks with UNN Harstad, for the extension of the emergency room to be during the day as well. At the beginning of April, the head of the department, the medical service, the municipal chief medical officer, the assistant municipal chief medical officer, the head of the emergency department and the head of the unit meet to continue working with immediate help and the use of triageTriage is a process where patients are sorted into groups based on their need for immediate health care. Triage is done in hospital emergency departments, emergency rooms and at accident sites and in disaster situations. at the doctor’s office. We have also obtained a knowledge base from other comparable municipalities on how they organize their immediate assistance during the day.
Toft goes on to say that there is a gap between the municipality’s and the State Administrator’s assessment of what the routine for patients who, on re-contact convey that they have become worse, should consist of.
– The municipality believes that such a routine should focus on the patient’s actual state of health in a current assessment, and not exclusively on whether the patient has been for a consultation a relatively short time beforehand. One can, for example, imagine cases where patients return after a short time, but still have a condition that is obviously not acute. The state administrator’s general feedback can be understood to mean that this patient group must also be prioritized more quickly than the state of health alone indicates.
– Does that mean that you do not want to change the routine that employees without medical training should prioritize who gets emergency appointments?
– We have not concluded on this. If such a practice is to be established as a norm, this will entail major organizational consequences for Harstad municipality, as well as for other municipalities. Against this background, there is a need to assess whether the State Trustee’s legal position can be fully accepted as a norm.
Selma’s son, Tommy, does not think the apology holds. The family is considering a lawsuit against the municipality. Not because there is a lot of money to be made, but so that others will not have to experience the same thing as Selma.
– There is a patient with an ongoing heart attack and is asking for immediate help, and they don’t understand what to do, exclaims Tommy.
The loss is great. A year after the death, Tommy was back in Harstad.
For the family, it is important that the municipalities tackle the challenges pointed out by the State Administrator. They hope that the practice will be changed so that sick people are assessed by a doctor.
– When they have made a mistake, it is important that they show with action that they want to change it, says Tommy.
The family has received the right to compensation from Norwegian Patient Injury Compensation.
In its justification, NPE writes:
“If the patient had been seen and examined by a doctor, and an EKG examination had been taken on 15 February 2023, it would most likely have been discovered that the patient had heart-related symptoms. She would then be referred to the specialist health service as immediate help. In the specialist health service, the patient’s heart rhythm would have been monitored and treatment measures would have been implemented against the patient’s heart problems. The patient would most likely have survived if she had not been sent home from the medical center without medical supervision.”
