Because of the complex and extensive nature of the underlying pathology, namely the extensive aortic dissection, "nothing could have been done to avoid the demise" of Stephen Mangion, a ministerial inquiry has concluded.

On 27 August 2024, Stephen Mangion, who was 55 years old, collapsed and died at 11pm at the Emergency Department of Mater Dei Hospital. 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.

A magisterial inquiry had been launched, which has since concluded and 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. 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.

Aside from the magisterial inquiry, on 29 August 2024 Minister for Health and Active Ageing Jo Etienne Abela appointed Judge Emeritus Joseph David Camilleri to set up an Inquiry, in terms of the Inquiries Act (Chapter 273 of the Laws of Malta) to establish the circumstances surrounding the demise of Stephen Mangion. The ministry published this inquiry on Tuesday.

In its conclusion, the Board, chaired by Judge Emeritus Joseph David Camilleri with Dr Herbert Felice and Ms Sylvia Spiteri as its members, said that: "After examining all evidence, including the autopsy findings, the Board is of the strong opinion that no single individual was responsible for the demise of Mr Stephen Mangion. Because of the complex and extensive nature of the underlying pathology, namely the extensive aortic dissection, nothing could have been done to avoid the demise of Mr Mangion. The dissection was probably already established when Mr Mangion felt the abdominal pain at 4 a.m. and had definitely extended to the aortic root by the time he presented to the health centre at around 7:10 p.m. complaining of chest pain. Controlling his blood pressure at such a late stage when the dissection was already so extensive would, in great probability, not have helped him at all and the final outcome unavoidable."

The Board said that in most modern medical services, no facilities or expertise are available to surgically intervene on extensive aortic dissections in the acute phase. No such facilities exist in Malta, it said.

"The Board unfortunately notes that Mr Mangion did not take good care of himself. He was a smoker and was non-compliant to treatment for hypertension and hypercholesterolaemia, factors which probably aggravated his condition."

"Long waiting times at the Emergency Department (ED) would be detrimental to any patient, especially those with chest pain secondary to ischaemic heart disease. However, in the case of Mr Mangion, it did not make any difference to his demise since the process of aortic dissection was probably occurring since 4 a.m. and the pericardial involvement happened suddenly at the moment of collapse." With this in mind, the Board said that it feels that the service needs to improve and put forwards a number of recommendations.

Among other things, the board noted the lack of continuity in documentation between Primary HealthCare and Mater Dei Hospital, and between professions within the same institution and department. The Board also noted an inconsistency in the mode of documentation in terms of hand-written versus electronic documentation. It recommends having a standard documentation system for doctors, nurses, and other healthcare professionals across all healthcare settings.

The Board also noted a shortcoming regarding communication between Primary HealthCare and Mater Dei Hospital after 4 p.m. during weekdays and during the weekend when the fast-track system is not operational. "Although at present all doctors can discuss referrals to the ED at any time with the lead decision-maker at the ED, the Board recommends officially extending the fast-track system to cover a 24-hour period, seven days a week."

The Board also said that it would be good practice for junior trainees to be encouraged to discuss high-risk patients with their seniors, especially when an ambulance is not immediately available to transfer the patient to the ED as happened in this particular case.

To the Board it appeared that there is no protocol/memo within Primary HealthCare to guide doctors in situations where the required ambulance is not immediately available. The board recommends that there should be a protocol/ memo in place in this regard. "If the patient/guardian refuses to follow the clinical advice, the patient and/or the guardian where applicable should assume responsibility and this should be documented by signing a relevant document."

The Board also noted that all Primary HealthCare centres have an ECG machine whereby 12-lead ECGs can be carried out by appointment. "Presently, when no ECG service is available, this machine is kept under lock and key in the ECG room and it is somewhat of a lengthy process to avail of it. The Board recommends the timely availability of a 12-lead ECG within all Primary HealthCare centres at all times and that all healthcare providers should be made aware of this."

Among other things, the Board also recommends that, "for high-risk patients identified at the triage stage, a decision-maker makes first medical contact at this point with a view to initiate investigations while the patient is waiting to be seen. Currently only an ECG is being taken when indicated (e.g. for ESI-2 chest pain patients)."

The board noted that during waiting time, the patient would have benefitted from reassessment of his circulatory state, with monitoring of parameters and clinical signs. "Pain relief and blood-pressure lowering treatment could have been considered. The fact that no cubicle was available should not have excluded the patient from receiving such basic clinical observations and possible initiation of treatment." The Board recommends that during very busy hours, a qualified person should be specifically allocated to go round the Clinical Area 1 seating area and reassess whether the patients' needs have changed. This information would then be relayed to the lead nurse/ lead doctor.

The Board also recommends adding certain parameters to the Emergency Severity Index assessment, "for example, chest pain patients who are expected to wait for a long time get repeated ECGs and repeated assessment of haemodynamic/ circulatory status, such as blood pressure, heart rate, and oxygen saturation. If a prolonged wait is expected, blood tests for cardiac enzymes should be taken on arrival. This is in line with international cardiology guidelines and is probably what happens in the ED from Monday to Friday between 8 a.m. and 4 p.m. when the fast-track system would be operational."

Referring to a memo which explains the procedure for ECG recording in patients who are classified as ESI-2 and present with chest pain, palpitations, or new-onset arrhythmias, the Board recommends that one point which reads "In case of normal ECG the disposition decision is taken between lead nurse and lead doctor according to work load and available cubicles", should be revised. "Patients should be managed according to their clinical risk as set by international guidelines and not based on ED bed and staff availability. This is clearly set out in the ESI handbook."

The Board noted that not all ECGs carried out on Mangion were uploaded onto the patient's dashboard. The Board emphasises the importance of booking and uploading all investigation results, including ECGs requested at triage stage. This will ensure that no investigation results are misplaced/ lost.

With the present ambulance and ED workload, the board said, "one should consider increasing the nursing compliment and setting up a dedicated ambulance nurses section (possibly using a rotation system) to avoid depleting the ED pool from nursing personnel. This would help to keep the waiting time for orange-coded ambulances (nurse-accompanied ambulances) to a minimum."

The Board noted that the long waiting time between triage and medical contact was primarily due to the unavailability of a cubicle and limited human resources. "The Board fully supports the Ministerial proposal for the expansion of the ED services as noted in the MDH Action Plan."

The Board also recommends prioritising the attraction and retention of ED personnel through various means, such as improving the work environment, family-friendly measures, etc.

"Currently, once patients have been worked up at the ED (A&E ready), they have to wait until a bed is made available in the wards, thus clogging and crowding the ED." The Board recommends having a designated area or ward where such patients can be transferred to allow timely assessment of new patients. These areas should not be administered by the ED personnel.

The Board also noted that some standard operating procedures (SOPs) are not always being updated and do not always reflect the present reality regarding workload, personnel, work environment, and current practices. The Board recommends that the relevant departments should regularly review and update all SOPs in place.

The Board, among other things, also noted that molecular autopsy for genetics was recommended by the cardiologist attempting pericardiocentesis in view of a documented family history of sudden cardiac death (SCD). "Unfortunately, this advice was not taken up by the pathologists performing the autopsy since this history was not adequately emphasised to them and because it was not directly related to the cause of death. Such information would be of clinical significance to the direct patient's relatives and possibly prevent further sudden cardiac deaths."

"Currently, Magisterial autopsy findings can be made available to the family after application to the Attorney General, which can be a cumbersome process to the family. The conclusions of all autopsy findings should be made easily available to the immediate family, barring legal concerns."

The ministry, in a statement accompanying the publication of the report, again offered its condolences to Mangion's family, and welcomed the suggestions made by the board as part of the ongoing healthcare reforms.

Read the full inquiry report here.