PHA reveals investigations findings on deceased dialysis patient

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Results of investigation re. deceased dialysis patient

PMH.

Investigations surrounding the unfortunate death of 25- year-old Neil Johnson, a dialysis patient at the Princess Margaret Hospital (PMH) has concluded. The internal investigation conducted by The Public Hospitals Authority (PHA) revealed that the patient (also known by the name Neil Bethel,) began receiving Dialysis treatment at PMH in October this year.

At the commencement of his treatment, Mr. Johnson received information regarding his diagnosis of renal failure, the requirements for renal replacement dialysis therapy and the ‘life and death’ implications of the scheduling requirements of his treatment plan. He was slated to have Dialysis on Monday, Wednesday and Friday of each week. Records retrieved from PMH reveal that he was non-compliant. During the month of December alone Mr. Johnson missed scheduled appointments on the 3rd, 7th, 10th and contrary to media reports, he also missed his appointment on the 14th of December. When Mr. Johnson presented on December 17th for treatment, all available treatment stations were in use and he could not be accommodated due to a shortage of staff in the Dialysis unit. He was clinically assessed in line with protocols and given another appointment date. Mr. Johnson was further advised to restrict his fluid intake to less than 500ml over the next 24-hour period, and to avoid high phosphorous and potassium containing foods like fruits, potatoes and citrus products. He was advised to return to ER if he experienced any shortness of breath, chest pain or chest discomfort symptoms that he did not manifest at that time.

Mr. Johnson left the Unit, but later returned to the Emergency Room where he was again triaged and assessed, and scheduled for emergent treatment at the Dialysis Unit 18th of December at 5am (the opening time of the Unit). Unfortunately, Mr. Johnson arrested at 4:30am on the 18th of December after multiple attempts to intervene were unsuccessful.

Patients who voluntarily miss treatments must report to the hospital’s Emergency Room for assessment. Before a patient is deferred he/she is evaluated and triaged, and then the next available time for treatment is given, usually within 24 hours.