The Igas report on Lucas' death in October 2023 in the Hyères emergency room highlights the delay in the service diagnosing the pathology from which the young man was suffering, in a context of "particularly" high activity that day.
The General Inspectorate of Social Affairs (IGAS) noted "several dysfunctions" which led to "delays and difficulties in the care" of the 25-year-old patient, who suffered from an invasive meningococcal infection.
"The first medical examination takes place almost four hours after the initial triage" (the initial examination by a nurse), whereas the data collected by the reception and orientation nurse should have led to an examination by a doctor within two hours at the most, notes the Igas in particular in the report made public on Friday.
"At the triage level, not all information is collected", in particular certain symptoms noted by the SAMU teams and "during treatment, the warning signals do not systematically trigger specific action", the report also indicates, noting that "the transcription" of information in the patient's file "is not systematic".
The triage, carried out in the meantime by two caregivers, "underestimated the seriousness" of his state of health, the Igas also notes. It still notes a delay in sending the biological analyses to the laboratory located in Toulon, compared to the planned procedures.
The specialists questioned by the mission believe, in view of the file, that Lucas should have benefited from "close monitoring of vital signs", and that the diagnosis should have been mentioned when his condition deteriorated.
However, they "cannot say that earlier implementation" of resuscitation procedures would have prevented a fatal outcome.
The report also specifies that the Hyères emergency services received 114 patients that day, compared to an annual average of 96 per day, during an intense summer period when the other emergency services in the Var were under pressure.
The Igas notes that the hospital implemented a "coherent" action plan for the emergency department after the tragedy, such as the reopening of short-stay geriatric beds (their absence had contributed to the overcrowding of the department on the day of the tragedy) or the creation of a nursing assistant position.
But it makes additional recommendations for the organisation of the service – "entrust the referring physician with the mission of supervising the allocation of patients to the nursing and medical staff in compliance with the treatment times" for example – or of the establishment: "re-study the possibilities of financing the extension of the premises of the Emergency department".
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