The magisterial inquiry which looked into 55-year-old former police officer Stephen Mangion’s death found that there was no negligence by the medical staff who attended to him and that they should not face criminal prosecution for his death.

Magistrate Joe Mifsud’s inquiry was concluded on Tuesday, which found that there was no evidence of intent, negligence, or delay by doctors and nurses who assisted Mangion the night he died at the Emergency Department waiting room at Mater Dei on 28 August of this year, after he complained of chest pains.

The 500-page report also calls for the re-introduction of imprisonment for defamation and the intentional spread of misinformation regarding third parties, due to the allegations spread on social media.

The report determined that Mangion, resident of Valletta, died from cardiac tamponade following an aortic dissection after he collapsed at the hospital’s emergency waiting room.

His death sparked outrage on social media, with claims that he had waited for hours despite complaining of chest pains, first at the Floriana health centre, and later at Mater Dei.

The inquiry, conducted with the assistance of several court experts, established that Mangion had first experienced symptoms at 4am on Tuesday 27 August, but delayed seeking medical help for 15 hours, despite being advised to do so from family and friends during the day. Experts used the CCTV footage installed in the two places Mangion attended to determine his movements.

During the day on the 28th, Mangion complained to his wife, with whom he was legally separated but maintained a good relationship, that he was suffering from extreme heartburn.

It also revealed that Mangion had not been taking his prescribed high blood pressure medication, as he claimed he had been suffering from an undisclosed side effect, and his symptoms were atypical and difficult for the medical team to diagnose the aortic dissection.

The inquiry concluded that doctors and nurses who assisted Mangion did everything possible to save his life. Mangion had underwent three ECGs, one at the Floriana health centre and two at Mater Dei, none of which indicated that he was at immediate risk of a heart attack.

Mifsud said that the medical staff could not have reasonably foreseen Mangion’s condition.

Mangion was driven and accompanied by his friend and nurse Donald Cassar, who also drove him to the Floriana health centre, and then from there to the Emergency department at Mater Dei.

The report revealed that an ambulance could not be dispatched to transport Mangion from Floriana health centre to Mater Dei as between 7.15pm and 7.46pm that night, 13 ambulances were in service, and none could be dispatched immediately.

The inquiry also showed that that day, 251 patients visited the Emergency department, with more than half classified as urgent. It was particularly busy between 7pm and 9pm, where 22 urgent cases were handles, an average of one case every 15 minutes. Eight of them complained of chest pains.

Between 8pm and 10pm, 41 new patients were registered at the Emergency Department, 25 of whom, like Mangion, were classified as urgent.

Mangion was given an ECG at the Floriana health centre at around 7.10pm, after which a doctor called Mater Dei’s emergency department requesting an ambulance for Mangion. He was told to keep an eye on Mangion as no ambulance were available, but one would be sent as soon as possible.

A second call to the department at around 7.44pm cancelled the request for an ambulance as Cassar had offered to drive him there.

Mangion registered his name after walking into the Mater Dei Emergency department and reaches the waiting room at around 8pm. 15 minutes later, he was assisted at triage by a nurse. He was then given a second ECG, before walking out of triage and waited in the zone in front of triage in Area 1, not in the main reception of the department.

At 8.24pm, a third ECG is administered to Mangion after he was approached by a nurse. None of the ECGs showed that he was at an immediate risk of a heart attack, however, tests showed that his blood pressure was high.

Mangion then returned to the seat he occupied and waits for an hour and 14 minutes, where he repeatedly stands up and makes phone calls. At 9.15pm, his brother Ronald Mangion accompanied him instead of Cassar.

At around 10.13pm, Mangion spoke to two different nurses, where one administered two paracetamol tablets to him. He returned to his seat.

At around 10.22pm, a man noticed Mangion seeming unwell, and reached out to him. Several nurses converged to assist him. At 10.25pm, Mangion collapsed and was assisted by Dr Josef Mifsud. He was then placed on a stretcher and taken inside, where CPR was performed before they reached the resuscitation room. Dr Pierre Agius and Dr Mark Abela aided.

At 11pm, Mangion was certified dead by Dr Josef Mifsud.

The inquiry report also described unfounded claims surrounding the case, which started from a fake profile named Manuel Debono, which instilled “unnecessary fear and alarm.”

Magistrate Mifsud said that the claims lacked any basis in eyewitness testimony or documentary evidence.

In his conclusions, Mifsud called for stronger protection to safeguard the reputations of public health workers when false claims are being made, while also proposing reconsidering the reintroduction of Article 252 of the Criminal Code, which previously prescribed imprisonment and fines for those convicted of intentional defamation.  The provision was removed when criminal libel was abolished in 2018.

The report also called on the police to warn certain individuals identified by a cybercrime expert, to refrain from commenting publicly in tragic circumstances before the facts are fully known.

In his report, the Magistrate praised Mangion’s family for publicly condemning those who used the tragic event to spread misinformation.

In a statement issued by the Health Ministry which published the magisterial inquiry, the Ministry said that it determined it was wise, and in the public’s interest, to publish the entire process verbale, even after some details were already published by the media, as well as because the inquiring magistrate recommended it due to the “public alarm” caused.

A copy of the inquiry was sent to the Health Minister, the Permanent Secretary for Health, and the Police Commissioner.