“Serious dysfunctions” had concluded the Minister of Health Agnès Buzyn about the treatment by the Samu of Naomi Musenga, 22 years old and mother, who died on December 29, 2017. “I am deeply indignant at the circumstances of the death of Naomi Musenga in December. I would like to assure her family of my full support and request an investigation by the IGAS (General Inspectorate of Social Affairs) into these serious dysfunctions”, observed the minister on Twitter on May 8.
The IGAS has therefore just report. This confirms that “the handling by the Samu of two successive calls concerning Mrs. Naomi Musenga does not comply with good practice and has led to a delay in treatment”. IGAS also points out that:
- The tone used in response to the call and the comments made are particularly shocking.
- The questions asked are not appropriate to the situation. The medical regulation assistant does not listen to the repeated cries for help interspersed with groans, the repeated mentions of physical suffering.
- The call was not forwarded to the SAMU regulating doctor, although the internal procedures at SAMU 67 mention the need to immediately forward any call for abdominal pain which is considered to be a sign of a potential life-threatening emergency.
Recall of facts
What happened to bring the case to the Ministry of Health? Back to the facts. On December 29, 2017, Naomi Musenga, contact the Samu from his accommodation in Strasbourg. She complains of violent stomach pains and explains that she is bleeding. The operator on the phone does not take the young woman’s worry and distress seriously. The recording of the conversation illustrates the tenor of the exchange. “If you don’t tell me what’s going on, I’ll hang up,” said the operator, whose comments were reported by the Latest News from Alsace. “I’m in a lot of pain,” Naomi replies with difficulty. “Yes, well you call a doctor, you call SOS Doctors”, replies his interlocutor. As Naomi tells her that she thinks she is going to die, the operator replies ironically: “Yes you will certainly die one day, like everyone else”.
Naomi then calls SOS doctors three times but gets the wrong number. She then contacts a relative of the family who goes to her home and finds her bathing in her blood. She calls the Samu again, who sends her back to SOS doctors. The practitioner who arrives on the scene immediately calls the emergency services for urgent care. The victim still alive is finally transferred to the hospital where she makes two stops cardiacbefore being placed in intensive care. Naomi dies a few hours later.
Consequences not proportionate to the seriousness of the situation
In addition to the shortcomings in the care of the young 22-year-old woman, the IGAS report also points to “results disproportionate to the seriousness of the situation” since the formal declaration of a serious adverse event (SAE) n was not made when all the elements were in place. In the conclusions of its report, the IGAS recommends accepting the resignation of the head of the Samu service and clarifying the roles in terms of reporting serious adverse effects, including those already the subject of a complaint or of a legal proceeding. It also recommends setting up training courses in good medical regulation practices at Samu 67.
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