Lessons from the magisterial inquiry into Stephen Mangion’s death

The inquiry carried out by Magistrate Joe Mifsud into the untimely death of Stephen Mangion in the waiting area of Mater Dei Hospital’s emergency exonerated all medical staff from negligent behaviour.

The serious medical condition that caused Mangion’s death was not detected because it presented atypical symptoms and three ECGs carried out throughout the evening did not indicate a heart attack.

At the Floriana health centre, Mangion was seen by a doctor and had an ECG test. The doctor recommended Mangion go to Mater Dei but an ambulance was not available at the time. A friend of Mangion, who is a nurse, opted to drive him to hospital instead.

It does not transpire that the time it took Mangion to reach the hospital was critical to his eventual death. Indeed, the inquiry found that what was more critical was Mangion’s 15-hour delay to seek medical attention from the moment he started feeling chest pains.

At hospital, Mangion was seen by a triage nurse and was classified as an urgent case. The inquiry found that there were 22 patients at the time classified as urgent cases, eight of them with chest pains. Two ECG tests were carried out on Mangion as he waited at emergency. The inquiry found that given Mangion’s symptoms and the test results the medical urgency classification he was given was correct.

It would seem, Mangion’s death was inevitable at that point since doctors had not yet diagnosed him with a damaged aorta that was causing blood to build in the artery’s walls.

The symptoms Mangion was describing to every doctor who saw him were not typical to the condition he had. The magisterial inquiry concluded that this factor, the length of time it took Mangion to seek help and the fact that he had long stopped medication for high blood pressure, meant medical staff could “not reasonably diagnose his condition”.

The magistrate ruled out negligence and insisted there were no grounds for criminal action to be taken against anyone.

However, the magistrate also made a pertinent observation on comments made on Facebook soon after Mangion died. These also formed part of his investigation.

One particular comment, which sparked outrage because it claimed that Mangion was left untreated in the hospital waiting area despite complaining with chest pain, could not be traced because the profile that made it was deleted. The probability is that it was a fake profile peddling false claims or half-truths.

However, the magistrate also reserved harsh words for former MP Jason Azzopardi and two other private individuals, who claimed on social media that Mangion died because of negligence. Ostensibly, these comments were based on the false claims made by the fake profile.

It has to be noted that Mangion’s death would have always raised alarm, given that he died in a hospital waiting area. The situation was only made worse by the spurious comments made by Azzopardi and others, which is why caution is required in circumstances like these.

The Mifsud inquiry has closed the criminal chapter unequivocally. However, a second independent inquiry set up by the Health Ministry to assess the medical care and procedures adopted in Mangion’s case is ongoing.

Hopefully, this second inquiry could suggest whether certain medical protocols need to be amended to cater for extraordinary circumstances like those that presented themselves in Mangion’s case.

The Health Ministry did well to publish the Mifsud inquiry in its totality. The transparency was necessary to allay fears. Similarly, we expect that the findings of the independent inquiry will also be published.

The fact that medical professionals were exonerated in Mangion’s case does not, however, exonerate the government from providing the necessary resources to improve healthcare services. People have experienced lengthy waiting times at the emergency department because of a lack of beds and staff shortages. These are issues the Health Ministry must address with urgency.

But at the same time, the Medical Association of Malta must also play ball when government decides to introduce new procedures at emergency that ensure better and smoother patient care. After all, the measures proposed by the Health Ministry are adopted in other countries as well – it’s not as if we are inventing the wheel.

While MAM has every right to defend its members, obstructionism for the simple sake of being difficult is not on and simply makes patients’ lives more miserable.