"Dysfunctions" during a busy period, causing a delay in diagnosis: the administration published on Friday its investigation report into the death of Lucas, 25, in 2023 in the emergency room of Hyères (Var), after septic shock.
The young man died during the night of September 30 to October 1, 2023, after hours of agony, the victim of septic shock linked to an invasive meningococcal infection.
"The first medical examination took place almost four hours after the initial triage" (examination by a nurse), while the data collected should have led to a medical examination within two hours at the most, notes the General Inspectorate of Social Affairs (IGAS) in this report made public on Friday.
"At the triage level, not all information is collected," particularly certain symptoms noted by the emergency medical services teams, and "during treatment, the warning signals do not systematically trigger specific action," the text states.
The Inspectorate also notes that "the transcription" of information in the patient's file "is not systematic."
At the start of the treatment, the classification by severity category underestimated the severity of Lucas's state of health by mentioning a reason for referral which was "not the main symptom", the Igas also noted.
The inspectors still note a delay in sending biological analyses to the laboratory located in Toulon, even if this element is "not decisive" in the evolution of the prognosis, according to the experts.
– “Endangerment” –
Medical specialists interviewed by the mission believe, based on the case file, that Lucas should have benefited from "close monitoring of his vital signs" and that the diagnosis should have been raised when his condition deteriorated.
However, they "cannot say that earlier implementation" of resuscitation procedures would have prevented a fatal outcome.
Experts point out that the pathology from which Lucas suffered is "uncommon and serious," that it often presents an "insidious onset of benign appearance," regularly leading to diagnostic errors, and that Lucas was admitted to the emergency room 19 hours after the onset of symptoms.
The Hyères emergency department experienced a particularly high influx that day: 114 admissions, compared to an annual average of 96 per day, during a busy summer period when other emergency departments in the Var region were also under pressure, some of which were closed at night.
The Samu (Smur) ambulance also went out twice as often as usual.
In Lucas's file, a doctor wrote, at 12:13 a.m., the note "hospital under pressure," specifying that there was "no room on the floors," "no cubicle" equipped with Scope (a monitor to monitor vital signs, editor's note) or "no stretcher available," and "only two doctors" present in the department. He emphasized that he had alerted his managers of a "patient endangerment."
– “Lessons” to be learned –
Furthermore, the patient's rights "were not respected," including the right to privacy during discussions with doctors, due in particular to the cramped conditions of the premises, which forced teams to crowd patients into the corridors.
The Igas, which is part of the social ministries, 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) and the creation of a nursing assistant position.
But it makes additional recommendations for the organization of the service – "entrusting the referring physician with the task of supervising the allocation of patients to nursing and medical staff," for example – or of the establishment.
At the national level, the inspectors identify "several lessons that can be learned from this death."
They propose in particular to raise awareness among doctors "about the early detection of septic shock", or to generalize the "triage grid" established by the French Society of Emergency Medicine.
In this case, the family filed a complaint for "voluntary homicide" against "x", against the establishment and its director.
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