Professor Ovadi Dagan, Director of the Cardiac Intensive Care Unit at Schneider Children's Medical Center, on Maidan Keller who died after using an e-cigarette, April 15, 2023/Spokesperson for Schneider Hospital
Seven months after the death of Meidan Keller, who was hospitalized at Schneider Children's Hospital due to a collapsed lung after smoking an electronic cigarette and died when disconnected from the ECMO machine, Walla! The detailed report of the examination committee established by the hospital and the Ministry of Health, which completed its work. The report shows that although the conduct of the entire department, from the head of the department to the nurses, was not good, the committee did not find any staff member to blame or responsible for the serious failure: "The staff was aware that they were not following the established procedures."
The report shows that a number of nursing staff members warned that Meidan was in a state of "restlessness," but the entire staff underestimated his mental state and did not take him seriously. Committee members found that the nurses made decisions on their own, whether to tie or release Meidan's hands, and did not always pass on the information to the medical staff. This was also the case on the day of his death.
On the eve of the tragic death, a psychiatric intern saw Meidan and assessed his mental state, but the report emphasizes that she "did not review the medical file and therefore gave partial and unhelpful advice." In addition, the head of the department, Prof. Ovadi Dagan, did not provide the intern with full information about the substances found in the electronic cigarette, which may cause a deterioration in his mental state.
Meidan Keller/Documentation on social networks according to section 27A of the Copyright Law
After the serious incident, the hospital claimed that Meidan disconnected himself from the devices and implied that it was a suicidal attempt. The report stated unequivocally that "Meidan unconsciously cut himself off and did not intend to harm himself."
The committee praised the department for quality child care as the largest department in Israel for ECMO treatments for minors. The report pointed out that there is in fact no other department that treats adolescents, and it is likely that special care should be prepared for adolescents connected to a heart-lung machine. "The staff is dedicated, skilled and treats extreme situations in pediatrics," it said. The committee members determined that the fixation of the tubes was very good, so that medical malpractice on the part of any of the staff members cannot be suspected: "The department leads the issue of ECMO in children. It is a hub of innovation and dedication."
16-year-old Meidan came to Schneider after being hospitalized at Kaplan Hospital following a collapse of his lungs. At the hospital, it was decided that he should be connected to an ECMO machine in a waking state. Four days later, Meidan forcibly removed the pipes, killing him.
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Schneider Children's Hospital. Petah Tikva, May 2015/Reuven Castro
Meidan Keller's family sent a response through attorney Yair Skalsky, calling the committee's rulings "very disturbing." "It is clear from the committee's determinations that other conduct would have prevented his death," they said.
Schneider Hospital said in response: "We have received the report of the commission of inquiry regarding Meidan Keller and we are studying it in depth and implementing its recommendations. The Cardiac Intensive Care Unit at Schneider Children's Medical Center leads the field of pediatric ECMO in Israel, and for over two decades has been treating hundreds of children in the rarest and most complex situations using this unique technology. We once again share in the family's grief."
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