This is one of the most serious, inconceivable and unusual medical malpractice cases discovered in recent years in Israel: A patient underwent complex surgery to remove a cancerous tumor, which includes resection of various internal organs – after which it became clear that the pathological examination that led to the surgical procedure belonged to another patient.
The case, which is being published here for the first time, took place on October 3, 2017 at the Sheba Government Hospital in Tel Hashomer, the largest and most central hospital in Israel.
The patient, 46 at the time of the incident, underwent surgery to resect a cancerous tumor, which is considered one of the most severe, extensive and has the most serious health consequences in surgery, and includes resection of significant parts of the pancreas, bile, stomach and duodenum. However, after the operation was performed it turned out to be completely unnecessary and misdiagnosed because the pathological examination relied on by the doctors was that of another patient who had been diagnosed with cancer, while the woman who had the extensive resection was not diagnosed with malignancy at all – neither before nor after surgery.
The case is so serious and unusual that in a very unusual statement in the hospital’s defense brief filed in the Tel Aviv District Court in the lawsuit against it, the medical institution admitted that “there is no dispute that there was confusion in the cytological answers and that the patient underwent surgery. It is disputed that at the stage she underwent the surgery, it was appropriate to offer her continued follow-up. “
“Abnormal medical malpractice”
The same patient is Iris Sabo, now 50 years old, living in Ramat Gan, raising her two daughters, 8 years old, and working in the field of information systems. In 2014, she was diagnosed with a cyst in the pancreas as part of routine medical follow-up, and in early 2017 she underwent an anesthesia test at Sheba Hospital to remove a tissue sample (biopsy) from the pancreas. After this examination revealed cancerous findings in the hospital laboratory, the doctors in Department B of Surgery B recommended to perform the large operation, known as “Wipple Surgery”, in which a large part of a row of organs is excised and is considered one of the largest and most complicated surgeries in general surgery.
Prior to the operation, a meeting was held between senior oncologists and surgeons in Sheba, who decided on the need for the huge operation, but in retrospect it turned out that they were based in their decision on an examination of another patient and not Sabo.
The operation was performed by senior surgeon Dr. Yuri Golds, and according to the indictment, “already after the operation they were told by the surgeon that he had never seen anything like it and did not see it at all that it was a cancerous tumor.” Indeed, about a month and a half after the operation, D. R. Golds told Sabo that “the operation was performed due to an error in the biopsy examination, and we made the surgical decision based on a biopsy that did not belong to the patient.”
Following this, Sabo demanded that the biopsy performed on her before the operation be re-examined at the Ichilov Hospital in Tel Aviv, and indeed it turned out that her examination before the operation was normal and no cancerous findings were found.
The statement of claim was filed against the Ministry of Health and the Sheba Hospital by Adv. Michael Elnatan of the law firm of Amikam Harlap, after two mediations between the parties failed.
The lawsuit states that this is a case of “severe and abnormal medical malpractice, with the unnecessary surgery performed on Iris being one of the largest and most complex surgeries in the world of surgery. .
The statement of claim also refers to Sheba’s management’s report to the patient on a series of technical and computer lessons learned in the hospital’s pathology laboratory following the affair. However, Advocate Elnatan claims in the statement of claim that “the hospital chose the easy way, when it finds it appropriate to draw lessons solely regarding the conduct of laboratory workers, but chose not to interrogate the ‘passion’ of the surgical system in the hospital itself to perform such a complex operation on the basis “A biopsy result, when all the other data indicated a complete irrationality in performing such an operation.”
According to the indictment, the huge and unnecessary surgery caused Sabo severe and irreversible damage to the digestive system and the ability to digest food, causing her tremendous difficulty in daily functioning, a severe tendency to life-threatening infections, general weakness and an increased risk of developing diabetes. The statement of claim is based on the opinion of Dr. Hadar Merhav, one of the top liver surgeons in Israel, and Prof. Yosef Zimmerman, a senior specialist in internal medicine and gastroenterology.
“I did not hear an apology”
The written defense on behalf of the Ministry of Health and Sheba Hospital contains a full admission of the serious mistake that led to the incorrect surgery. However, it was argued that she should have undergone the surgery anyway, and that “the recommendation for surgery was expected to be accepted within a year, two or five years, whether she developed an invasive pancreatic tumor or as a preventative surgery for fear of malignant change.” It was also alleged that her complaints about the damages following the surgery were “excessive and unfounded”.
The defense brief is based on the opinion of Prof. Yoram Kluger, director of the surgical department at Rambam Hospital and chairman of the Association of Surgeons, and Prof. Zamir Halperin, one of the country’s leading experts in gastrointestinal and liver diseases (gastroenterology).
“The operation itself lasted eight hours, and the surgeon said afterwards that if it was cancer then he had never seen such a tumor,” Sabo says in a conversation with Israel Today. “Recovery from the surgery in the ward was very difficult. After a month and a half I went to the surgeon, and he was all smiling and told me I would be very happy to hear the answer that I have no cancer, explaining that ‘the surgery was based on another patient’s biopsy.
“I was shocked. I underwent one of the largest and most complex surgeries in the world of surgery, which has serious and significant health consequences for my lifestyle, and the doctor asks me to rejoice at the mistake made? I did not believe my ears. At first I did not believe him. “I told the truth. I called the oncologist who accompanied me, and she told me that everything was fine with me. I went into anxiety and took the original test to Ichilov – and indeed it turned out that there were no findings.”
According to Sabo, “the surgery has led to a wide range of severe medical and functional problems that I have to deal with on a daily basis.”
And what would you like to say to Tel Hashomer?
“You made such a huge mistake, so stand behind what you did – and treat accordingly. Even on a personal level, I have not heard an apology. Today I have to fight against them for my future, literally. I am a single mother of two daughters, and everything is much harder now. I feel the body My course and I fail to do basic things. I am very worried about the future, as I may develop further illnesses down the road as a result of the surgery.
“They did not bother to present to me the full investigation report they prepared, but only the conclusions of the report and the lessons learned. Why hide it from me? What is it helpful for? To this day I do not know exactly how such a serious mistake occurred. And now, the hospital I want me to prove to him that what I claim I am suffering from is real and true, even though they also know the serious consequences of such a huge surgery. “
Sheba Hospital: “Human error”
Advocate Elnatan, representing Sabo, told Israel Today: “The medical staff of Sheba Hospital was clearly negligent in this case, and Iris’ life was literally destroyed.
“Our expectation was that at least in the unique circumstances of this case, the competent authorities on behalf of the hospital would do everything in their power to compensate her in a manner commensurate with her severe damages. We are sorry that the hospital failed to do so, All this means that Iris is now forced to fight for her right to adequate compensation in court, in an expensive and lengthy procedure. However, there will be no shadow of a doubt that this conduct will receive an appropriate response in court. “
Sheba Hospital said: “Sheba Medical Center prioritizes the safety of the patient and the patient. Unfortunately, this is a human error that is considered an inconvenient event for us, and so was the treatment throughout. Upon learning of the mistake, the incident was reported to the Ministry of Health and will be investigated at all medical center levels. .
“Following the investigation, the work processes were changed and the first technological measures of their kind were purchased in Israel, designed to ensure that such cases do not happen. It is important to emphasize that throughout Accompany her as needed. “