Guest Post: The Scapegoat Of Mount Carmel

2017 was the year I started out as a doctor. My first job was in Mount Carmel Hospital – Malta’s outdated, self-labelled “Asylum for the insane”. It was in a bad state then, not much different to how it is now.

2017 was also the year that Joseph Pace, one of Mount Carmel’s longest-serving nurses, had to intervene in an emergency situation where a patient in hospital injured themselves. 

Joseph should not have had to intervene in this case personally. The patient’s caring psychiatric team had recommended that they be supervised by a nurse, one-to-one, at all times. 

Due to the fact that the organisation – Mount Carmel Hospital/Mental Health Services/Ministry of Health – did not employ enough staff (and continually fails to do so), this patient was left alone, and the situation unfolded as it did.

This week, it transpired that Joseph is being prosecuted by the police for criminal misconduct relating to this incident and may face up to nine years in prison. 

As with any adverse patient event (i.e. a patient in a psychiatric hospital prescribed constant supervision still managing to perform significant self-directed injury), a root-cause analysis should be conducted in order to find out what went wrong. The aim is to avoid repeating mistakes that have already been made, that organisations should learn from their errors. 

The literature on patient safety here is quite clear: create a culture of patient safety. This means that we avoid blaming one person for an adverse event. 

The rationale behind this is manifold: adverse patient events are rarely the sole responsibility of one person so it is usually unjust to blame one person. Also, if individuals feel they have made mistakes, they will be reluctant to discuss their mistakes if they suspect that their job or freedom could be threatened by doing so.

Root-cause analyses and safety cultures are strongly present in industries where mistakes are considered genuinely unacceptable – aviation, engineering, nuclear industry, and in some healthcare settings. Those who want a more in depth case-study of what an organisation without a robust safety culture looks like, should watch the HBO series Cherynobyl.

Facets of healthcare in Malta show disappointing disregard for safety culture. I am personally affected by Joseph’s story, because it could easily be me up against a court for something that I either did or did not do that later became associated with an adverse patient outcome. 

I am a doctor, and as a part of my government service, I must work regular shifts that last 32 hours (like most government doctors do). If, after being on shift for more than 24 hours, I make a decision that harms a patient – who will be blamed? The exhausted human, or the absurd system? The people at the top of our healthcare system have been warned about these hazards, but the workers are the ones who will be blamed, should things go wrong.

In Malta, we need to work towards attaining the collective maturity to discuss our mistakes without scapegoating individuals to the detriment of wider society. 

In 1984, in the USA, a young woman named Libby Zion died as a result of successive errors made by sleep-deprived medical staff in a New York State Hospital. She was overprescribed medications leading to the rare but fatal serotonin syndrome.  Zion’s father just happened to be a State Attorney and influential journalist. Incensed by the fact that his 18-year-old daughter had been killed due to a medical error, he instigated a protracted lawsuit which resulted in the USA banning shifts of longer than 24 hours.

The court case of Libby Zion is well-known amongst healthcare workers and has probably saved many, many lives. The Malta Police Force and Mount Carmel, in their almost infinite ineptitude, should stop their witch-hunt of Joseph Pace and perform a root-cause analysis of the incident so that Mount Carmel can improve the service it offers.

The persecution of my colleague, Joseph Pace, will save no lives and will do no good. It is an attempt to execute his soul at the altar of a health system which lacks the maturity to perform even a basic introspection.

Joseph Pace, I’m so sorry that this is happening to you. If you are convicted, in a way, we all are.

Dr Alexander Clayman graduated as an MD from the University of Malta in 2017 and is passionate about mental and reproductive health.

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