Raul Martinez / EPA
The death of an elderly man ventilated at home during the blackout in April will result from the caregiver’s delay in responding to the alarms of the equipment, the late activation of help and systemic communication failures, according to Igas.
Maria Amália Freitas78, during energy failure on April 28.
The investigation of the General Inspection of Health Activities (Igas) analyzed the case, to find out whether the user received the help provided by INEM “with ready or in a time considered acceptable.”
According to Igas, the failure will have been in the caregiver delay in taking the necessary steps.
“Global analysis of the facts shows that, although the medical emergency media has worked with available, the time interval in the activation of the caregiver and response by the caregiver before the equipment alarms, associated with systemic communication failures, will have contributed to the final result,” reads the IGAS report project, which Lusa has now accessed.
According to statements made by the child and caregiver of the user, on April 28, around 11:35, following the electricity failure, the ventilation equipment used by the mother, whose load registered 100%, continued to work, through the activation of the internal battery.
“About 3:47 pm, following the fan alarm shooting of the fan and the verification that the battery charge was only 50%, called 112, to ask for help, information that was revealed incorrect compared to the equipment alarms available by the supplier company,” Igas points out in the report that was revealed by.
When firefighters arrived at the scene, the battery charge registered 0% and the equipment stopped working. And that, according to the same records, will have occurred, after all, around 3:17 pm.
The caregiver admitted that his mother will have deceased About 10 minutes after I called 112, even before the firefighters arrived at the scene.
After analyzing all the records and clarifications provided by INEM, Igas found that, despite all the exceptional embarrassment verified on the day of the blackout, “the usual procedures were followed, which seem correct and effective in the performance of INEM” regarding the readiness’s readiness, the care of the caregiver and in the activation of relief means.
Several factors dictated this outcome
“The conjugation of a clinical situation of extreme ventilatory dependencea absence of energetic redundancy more robust in this framework of exception of energy breaking in terms of duration and territorial scope, the delay in the 112 call and the weaknesses of the system Emergency communications may have compromised the possibility of more effective medical intervention, ”he concludes.
Igas emphasizes that the death of the user in the context of blackout “reflects systemic vulnerabilities that require a coordinated and multisectoral response.”
“The safeguarding of the life of patients ventilated at home cannot only be based on the technical adequacy of the equipment, also depending on the robustness of surveillance systems, caregivers’ preparation and the readiness of emergency communications”He warns.
In this sense, Igas makes two recommendations to INEM and one to the Directorate-General for Health, which aim to correct the factors identified as critics in the report.
To INEM, they propose Introduction of reinforced criteria in the screening of CODOto rapidly prioritize vital risk situations associated with energy interruption on ventilatory support devices, as well as the reinforcement of the interoperability of operational communications.
To DGS, Igas proposes the elaboration or review of a specific technical guidance standard for home ventilationwhich incorporates minimum energy security criteria, individual contingency plans, obligations of supplier companies, caregivers education and clinical registration of vital risk.
