Dubai medical negligence law spotlighted after patient left brain damaged due to alleged Mediclinic violation.
Case Summary & Background - Mediclinic Negligence Claim
The family of Mohammad Imran Hussain and a group of senior American medical professionals shared their analysis of the case and advised Detained in Dubai as follows:
Mohammad Imran Hussain (Imran), 50, lived in Dubai and is married with four children. His career flourished and he was head hunted by Dow Chemical in 2011, to work as their business development manager. He exceeded performance expectations.
On the 1st of August 2016, Imran was admitted for heart surgery to Mediclinic, located within Dubai Healthcare City (DHCC). The operation was successful and Imran was soon due to be discharged. One of the final post steps prior to discharge is to remove the “pacer wires” that are externally connected between an area next to the heart and a bedside device.
Complications are known to arise from the removal of the pacer wires and can result in the death of a patient if not diligently monitored by the healthcare team. One of the most feared complications is called cardiac tamponade, where bleeding occurs around the heart. The bleeding causes the heart to become compressed and its ability to pump blood begins to fail.
The symptoms of cardiac tamponade (shortness of breath, low blood pressure, elevated heart rate) are easily identifiable and nursing and medical teams caring for the patient must be instructed to observe for any symptoms or signs of cardiac tamponade. As cardiac tamponade is a recognized but potentially deadly complication after removal of epicardial pacer wires, preparing and monitoring for this complication should be expected of any respected hospital.
On the 10th of August 2016, the cardiac surgeon removed the pacer wires at 08:05. There is no evidence available that the healthcare team was qualified to detect this complication. Furthermore, there is no evidence that the Mediclinic healthcare team was properly prepared for the potentially severe complications that could ensure after the pacer wires were removed from this trusting patient.
It is standard international practice to plan for procedures and interventions, preparing the patient and responsible health care teams to carefully monitor for potential complications. No physician works in a vacuum. Particularly with complex procedures like heart surgery, a competent health care team is required to properly care for the patient and minimize complications. The team is composed of the primary treating physician and all other hospital staff members charged with the responsibility of caring for the patient.
Mediclinic’s team appears to have failed in their duty to prepare and monitor for such complications, lacking a clear plan for monitoring or emergency response in the event of cardiac tamponade. Although it is not a common complication, it is well-recognized and one of the most feared after removal of epicardial pacer wires. Unlike many medical situations, this can allow a degree of preparation and education on a case-to-case basis to assure that it is recognized as early as possible if it does occur and that intervention is not unnecessarily delayed. Not all medical procedural complications allow the luxury of such preparation ahead of time, and this is one dimension to the tragedy of this case.
Approximately 1 hour after the removal of the pacer wires (09:30), clear symptoms of cardiac tamponade were noted, and they evolved with increasing clarity thereafter. However, it was 83 minutes after his symptoms began that he finally had the necessary bedside procedure to save his life. Unfortunately, this delay led to his heart stopping with his brain deprived of oxygen and blood flow long enough to cause permanent brain damage that has left Mr. Hussain with permanent dependent disability.
Imran’s case has been reviewed by several international expert specialists, including a well-respected cardiac surgeon from the US who stated that: “Mr Hussain developed the classical symptoms of cardiac tamponade. The delay from onset of symptoms to intervention (1 hour and 23 minutes) was unnecessarily long. The treatment of cardiac tamponade is not overly complex and can be executed rapidly. Had the team been well prepared, the first noted symptom of shortness of breath and excessive perspiration at 0930 am would have led to rapid recognition of its significance and bringing together the team who should already have been “on alert” to confirm the evolving cardiac tamponade and intervene without allowing progression to the extreme that occurred in this case. It is clear to me that the confluence of events led to a completely avoidable catastrophe”.
Radha Stirling, CEO and founder of Detained in Dubai, has reviewed the available medical analyses and medical reports written by a US expert neurologist, who has visited Imran on multiple occasions who indicated that; “Mr Hussain suffered a heart and breathing stoppage on August 10th, 2016, due to cardiac tamponade, as a complication after removal of pacer wires approximately two hours earlier. Severe low blood flow injuries to the brain as suffered by Mr Hussain are expected to cause variable degrees of permanent disability.” Now, one year after his brain injury, Mr. Hussain is permanently dependent for everything. He cannot speak or comprehend language, eat, or control his arms and legs. He is bedridden, incontinent, and unable to control his environment at all. He requires full time, round the clock care and is completely dependent on others, essentially leaving behind his wife, children and family; Sadly, he cannot even recognize his mother.
What is clear is that the delay in recognition and treatment for cardiac tamponade is what caused the patient to go into cardiac arrest and suffer permanent and irreversible damage to his brain. Had the medical team been prepared for complications, Imran would have continued to live a normal life. The delay in diagnosis and treatment, preventable, cause of the injury. This resulted from a lack of case preparation and planning, rather than a lack of surgical skill. the Mediclinic healthcare team failed Imran.
Negligence Claims in in the UAE - Will Dubai be able to assess claims independently?
Imran’s family, upon learning what exactly caused the brain injury, made a complaint to the Dubai Healthcare City Authority (DHCA). The DHCA provides one of the possible avenues for victims of negligence to seek remedy, their role is to review complaints and make rulings which can be advantageous in compensatory claims. Essentially acting as a medical ombudsman, both parties are able to make written submissions for the DHCA to review. Unfortunately, the review and decision making process is behind closed doors; The DHCA requests their own “experts” to review evidence but the claimant is not necessarily provided with the evidence so that he or she may contest the findings or provide their own expert evidence to be considered.
The DHCA initially found that there was a clear “mismanagement in dealing and recognising the main complication (cardiac tamponade)”. The DHCA ruled to suspend the license of the cardiac surgeon and to issue a “warning letter to Mediclinic City Hospital for the system failure”, particularly because they had no backup surgeon readily available.
The victim’s family and team of experts felt that the findings in this case, while appearing to be in favour of the victim, were inaccurate in determining the actual causation of the injury which was not entirely due to a surgeon being unavailable but more due to a lack of overall case, staff and patient preparation. According to the claimant experts, confirmation of cardiac tamponade should have been no later than 09:45 AM.
Mediclinic appealed the decision and their appeal was accepted, without the possibility of making further submissions.
Radha Stirling commented “It would be a great challenge to obtain a fair and unbiased ruling via the DHCA or other government body. Dubai’s goal is to become a world centre for just about everything, whether it is arbitration, development, technology or medical tourism. Dubai’s tendency has been towards marketing and public relations over functionality and we have seen that overall, they would rather hide issues than address them. Dubai Healthcare City has been founded to promote medical tourism and any adverse judgments regarding negligence may negatively impact the city’s reputation.
The DHCA is by no means an independent committee. Part of their role is to promote medical tourism. This factor coupled with Mediclinic being one of only two hospitals and Dubai Healthcare City´s largest investor, renders it impossible for rulings from the authority to be considered independent.
It is important in healthcare that all misconduct and negligence claims are reviewed independently. If mistakes in process are allowed to occur without accountability, more lives will be lost and Dubai should not be considered congruent with international medical standards. If medical tourists are aware of such a flaw, they will likely seek treatment in other more established countries.
If Dubai wants to promote itself as a world medical centre of excellence, it must promote accountability in the medical community. Given that the DHCA decisions are made in a secret manner, we can not be confident in their determinations. The only way for a claimant’s case to be properly assessed is through an open court hearing, where both the claimant and the respondent can provide evidence to the court for consideration. Even then, in Dubai, we have seen that the judicial system remains open to abuse, coercion and corruption and we still can not be guaranteed a fair hearing, particularly with so many government vested interests at play.
One of the biggest issues that I see in opening a claim in the civil courts is that the courts will give weight to the decisions of the DHCA, even where it may be clear that the decision was wrong. It is unusual for a Judge in the UAE to rule against government interests.
Imran’s family has applied for financial remedy to the Dubai Courts. Essam Al Tamimi is representing the respondent. Al Tamimi has issued a counter claim against Imran´s brother to seek AED 1,300,000.00 in medical fees for Mediclinic and court costs. Of course, Imran’s brother can not be found liable for the fees. Al Tamimi argues that since the DHCA has reached a decision, a claim in the civil courts is frivolous. On the contrary, it is the only true option for victims of medical negligence to seek damages and, while the court may take into account the authority’s findings, they are expected to hear evidence that would not be given weighting otherwise.
Recommendations
Dubai has set high goals in its pursuit to become a destination for medical tourism; seeking to be considered as a provider of medical care that meets “international standards”. Medical negligence claims in the UAE are on par, per capita, with claims in the UK which are on the rise in comparison to US claims, causing the matter to be raised at the Arab Health Conference in 2013.
There are three methods to seek remedy for a medical malpractice or negligence claims in the UAE. One can apply to the Dubai Health Authority for a misconduct ruling; open a criminal case against the alleged negligent party; or take civil action through the courts. In all scenarios though, the courts rely heavily on evidence provided by the DHA. Thus, if the DHA’s findings are unsatisfactory or biased, the claimant has little recourse, even if action is taken via an alternative remedy path. It is important to allow truly independent reviews and compensation to victims. Promoting accountability within the medical community is the only way to ensure constant improvement to standards.
The UAE is known to “cover up” human rights violations and censor any criticism of government bodies via their Dubai Media Office and Telecommunications Regulatory Authority where it is deemed to be in the best interests of the government. Journalism is largely restricted and criticism is criminalised. In line with the government views of negative publicity, of course the DHCA will not been inclined to rule in the favour of claimants because this would negatively impacts the country’s image. In fact, it is obliged to protect and promote the UAE’s reputation, even where unfair and to the detriment of victim claimants. This view is short sighted though, and in fact, it improves the reputation of the country to acknowledge mistakes and to improve them.
Sheikh Ahmed bin Saeed Al Maktoum, Chairman and CEO promotes Dubai Healthcare City; Mediclinic is one of the two operating healthcare providers and therefore, largest investors. There will naturally be an inclination to protect Mediclinic and other investors from financial penalties.
See Sheikh Ahmed’s promotional video here:
https://www.youtube.com/watch?v=wp6mvRpmaR8
Dubai needs to understand that transparency and fairness will improve the reputation of the country, not detract from it. Their investors, like Mediclinic, need to be held accountable to promote diligence in the medical industry.
Resources:
http://independent.ae/3685/dubai-based-heart-surgeon-suspended-for-mismanagement/
http://gulfnews.com/news/uae/health/hospital-warned-after-man-lapses-into-vegetative-state-1.1927029