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At times reporting stories , may sound like jokes that could even tear away a smile, so far the end of the story lies from any logic. Unfortunately, though, when these matters concern health, the “aftermath” tells of personal tragedies, invalidities and deaths. There is nothing to laugh about, and hearsay has it that being rescued by a doctor today seems to take on a ever more ominous mask of a lottery game, where, if you are lucky enough, you may be cured, but if not you risk losing your life. Un trend on the rise, which if on the one hand, is proof of a general decline in the training of doctors already starting from university up to the inconsistent availability of training updates, on the other, the reputation of thousands of doctors is ruined, those who carry out their task with scrupulous duty, but inevitably are overwhelmed by what is termed in modern day jargon “an ill-functioning health system”

A term, the latter which is synonomous of bad organisation, the non-implementation of correct health-care protocols, the unfulfilled management and the statistics are quite clear: the damages incurred on the private citizen are to be attributed 70% for a lack in facilities and services in the hospitals and lack of organisation, 30% for errors made by doctors and nurses alike”. Codacons (association for the protection of the consumer) has reported the figures to the technical commission on clinical risks established by the Minister of Health. “In Italia about 90 patients on average die due to mistakes made by the hospitals, deaths that can and should be avoided.

Just like the case-absurd a sit turned out to be – which was recently tackled by the Court of Auditors in Tuscany, case n.68/2015, where a man died following the treatment he received on ambulance. Let’s see in detail. A Roumanian 24year old, stopped for drunken driving, was taken to police Headquarters in Montecatini Terme and locked up in a room that had a glass door and where there was no furniture or finishingsfor safety reasons. The ambulance was called and in a few minute sit arrived. The youth was given an injection of Midazolam 15g by the doctor on duty for “ his state of agitation, cute intoxication from alcohol, and alcoholic breath-halitosis”.

Following a couple of hours, the ambulance moves away and the patiet falls asleep. Approximately 50 minutes pass and the police realise that the conditions of the boy they had stopped were getting worse. They called the ambulance again, which arrived punctually, only to find that the youth’s heart had stopped beating. It was useless by now, the youth had passed away.

The State prosecutors of the Republic in Pistoia open a legal proceeding againste the previous doctor who had administered the medicine, and it was then that the bare chilling truth came out. Death had come for “acute depression of the respiratory organs”, in short from suffocation. The administration of 15 mg of Midazolam given intra-muscular proved to be lethal.
A series of superficialities: the rule stipulates a dose equal to 0,07 – 0,1 mg/kg which, in the case of the youth weighing about 80 kg ,should have only been about 5,6-8 mg.

Another violation of the rule: the medicine was not to be used in the presence of alcohol; which in fact meant a significant enhancement of the sedative effect given by Midazolam. Fatal error: a slap in the face to the confidence of the private citizen who should have faith in the public health system.

The criminal proceeding in question has ended with ruling of the Court of Pistoia n. 1152 on 20th May 2011, which became definite on 16th July 2011 which sentenced the woman to six months imprisonment, then substituted with a financial penalty amounting to 45.000 Euros. The mother of the unfortunate youth received 230.000 Euros. No respect for the life of a son, a serious damage to the public money taken from the taxes paid by the citizens.

Translation provided by Marina Stronati


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