The late Nachshon Har Zvi died on December 7 at the age of 78, following a malfunction during a catheterization at Beilinson Hospital - and his family will appear today (Thursday) for the first time before the inspection committee established by the Klalit Health Insurance Fund, which is investigating the circumstances of the case.
Those around the family fear that the composition of the committee may be tainted by a conflict of interest, and according to them, in light of the fact that most of the members of the committee are Kalit employees, it seems that the fund is checking itself.
Nachshon Har Zvi.
His condition deteriorated rapidly, photo: from the family album
As a reminder, Israel Hayom learned that the malfunction occurred when, during a routine catheterization operation at the hospital, the X-ray system that allows the reflection of the blood vessels stopped working. Har Tzvi was left with the catheterization equipment inside his body, and the catheterizers could not finish the operation because the screen did not work. Within minutes He was transferred to the nearby catheterization room, which fortunately was free, but despite this his condition deteriorated. The doctors performed CPR on him - but had to pronounce him dead. This is the same malfunction as the one that happened about two weeks before the fatal event, as we previously published.
Additional details that we are publishing now show that the first malfunction occurred during the stage of turning on the equipment, before the catheterization, and did not cause injury to anyone.
After that, the faulty screen was replaced with a used screen, not a new screen.
The used screen was fine for only two weeks until the malfunction that led to the disaster.
"The darkening of the screen is a technical fault," says a senior member of the HMO.
"It is clear that the medical team, which performs thousands of catheterizations a year, did not fail here. No one expects the committee to shake their heads, but rather to present engineering solutions to the aforementioned malfunction. The committee can recommend bringing in an additional backup screen, or check whether the faulty threshold should have been replaced with new equipment, and not used. It will offer engineering solutions."
"Strange behavior of the cash register"
The inspection committee was appointed four days after the malfunction.
She was expected to finish her work by January, but the publication of her conclusions was postponed.
Now it turns out that not all the testimonies have been heard before the committee, and the target date for the publication of its conclusions is probably in two months - at the end of March.
The committee is chaired by Prof. Aharon Primerman - Director of the Interventional Cardiology Unit at the Hillel Yaffe Medical Center.
The members of the committee are the retired judge Verda Maroz;
the medical engineer Bezalel Meirenz (who previously worked at Hillel Yaffe);
Deputy Director of the Cardiology Unit at the Carmel Medical Center of Klalit, Dr. Amnon Eitan; Dr. Furia Shaf, senior physician at Klalit;
and the director of the department for assimilation of medical technologies in the hospital division of Klalit, Eli Kerko.
Today, as mentioned, the family members are expected to present their testimony regarding the events that happened in the catheterization room in Bilinson, and will be able to ask questions and be updated on the progress of the committee's work.
In connection with the family, photo: Yehoshua Yosef
"One of the things that seems strange to us is that the committee is supposed to be neutral," says one of the family's relatives.
"Kallit presented as if it was an inspection committee in cooperation and coordination with the Ministry of Health, but in reality - half of the members of the committee are Klalit employees. They need to inspect and investigate a subsidiary of Klalit called 'Kallit Engineering'."
He further adds: "We were constantly given to understand that Billinson was excluded from the investigation, but the person who summoned the family to the hearing is a hospital attorney, who is responsible for risk management. All these things indicate that the committee may not be objective in the extreme. After we meet with my members committee, we will consider whether to contact the Ministry of Health and demand an external and independent committee."
Another interesting claim regarding the investigation of the affair, comes from a consultant for medical device companies on regulatory and cyber issues.
"There is an unreasonable length of time for the committee's work, and a delay regarding the question of whether it could be a cyber attack," he explains to Israel Hayom.
"Only a month after the incident, Klalit consulted with an Israeli company in the field of cyber protection. And where is Philips in this story? Did they give technical answers? Maybe the national cyber system should have been consulted as well. Because of the rarity of the incident - clear answers are needed."
"Careful examination of the subject"
A general response from the CPF: "The inspection committee was appointed in coordination and agreement with the Ministry of Health, and the names of its members were published to the public.
The chairman of the committee is a cardiologist from Hillel Yaffe Hospital.
Not every inspection committee includes a representative of the Ministry of Health.
"The committee is conducted independently and independently, and it is sovereign to conduct its work according to its professional judgment. We are confident that the members of the committee will do their work faithfully, in a professional and transparent manner.
"The committee is entitled to summon and consult with any relevant party to examine and clarify the circumstances of the event it is examining. In order to carry out a thorough examination process of all aspects, the work of the examination committees often takes several months.
"Naturally, the manufacturer of the device is involved in the inspection. The hospital's risk management officer is not a committee member, and is not involved in the committee's work, but only in the organization and logistical and technical coordination with the hospital, in order to enable the committee to work orderly.
We return and participate in the family's grief, and a representative on our behalf is in regular contact with them."
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