Dr. Ahmed Salamat

The sad story of a young pregnant female that was posted recently by Dr Kurer on Ibnosina website is not unique and won’t be the last tragedy.

In such atmosphere, rumours rife and it becomes difficult to separate facts from baseless and unfounded allegations. However, I am personally aware of 2 confirmed fatal incidents which I think deserve transparent, thorough and independent investigations at least to restore some public confidence in our healthcare system.

Case1---In the first week of June Nabil El Behilil 22 year old young lad died tragically at Tripoli Medical Centre. I knew Nabil very closely and I tried my best to facilitate his treatment in London. Nabile was diagnosed with severe pancytopenia and strangely labelled as Refractory Anaemia with Ring Sideroblasts (RARS). He came for platelet transfusion at TMC; instead he was brutally beaten to death, resulting in him bleeding to death as it was reported on the Shababiya and Aljamaheryia channels. The hospital death certificate was issued with severe thrombocytopenia as the cause of death. His remains were excavated by the corner for post-mortem examination. I am really shocked with tears and could not comprehend the entire situation. Since it is now court case I do not wish to comment on the quality of care he received in the 9 months before his brutal blow.

Case2---On Sunday 27th September 2009, two young ladies underwent routine cholecystectomy operations, one in her thirties died few hours after surgery presumably because of internal bleeding. Lady number 2 in her forties was slightly luckier due to the chance presence of an experienced surgeon in the department who was able to stem off the nipped major bleeding vessel. The lady was admitted to surgical ITU on a knife-edge struggling for her life and I do not know her final outcome. Understandably, I was told that most surgical patients discharged themselves after these devastating events.

Such recurrent worrying and tragic patient stories must give the Secretary of State for Health Brother Mohammed Hejazzi the strongest impetus to establish urgently an independent National Libyan Patient Safety Authority to oversee and improve patients’ safety. This is well-tested and robust system in many countries to improve patient safety and an efficient way to improve the health standards.

In the united Kingdome for example, it was reported that £8 billion was the bill to settle patient claims in the last 5years (the figure sum was refuted by some). The National Patient Safety Agency (NPSA) was established to lead and contribute to improved safe patient care.

Through its three divisions the National Patient Safety Agency covers the whole UK health service including the private sector.

1- National reporting and learning Service (NRLS)

Through its national reporting system the NRLS aims to reduce risks to patients receiving NHS care and improve safety. It collects confidential reports of patient safety incidents from healthcare staff across the country. Clinicians and safety experts help analyse these reports to identify common risks and opportunities to improve patient safety.

It is mandatory for hospitals to report all serious patient safety incidents as part of the Care Quality Commission registration process. Since the NRLS was established in 2003, over four million incident reports have been submitted by healthcare staff. Most incidents are submitted electronically from local risk management systems.

Feedback and guidance from the agency are provided to healthcare organisations to improve patient safety. These include alerts to address specific safety risks, tools to build a strong safety culture and national initiatives in specific areas.


2-National Clinical Assessment Service (NCAS)

Supports the resolution of concerns about the performance of individual clinical practitioners and ensure their practice is safe through giving expert advice and support to local healthcare organisations and their staff and helping healthcare services deal effectively with performance concerns.


3- National Research Ethics Service (NRES)

NRES aims to protect the rights, safety, dignity and well-being of research participants in clinical trials and other research within the NHS by maintaining a UK-wide system of ethical review via NHS Research Ethics Committees (RECs).

Finally, the Agency also commission and monitor several confidential enquiries into patient outcome and death

To conclude, the patient safety must be top priority for all health care workers, the issue is vital and complex and there is no easy fix. The first step on the road to recovery is to get out of the state of denial and accept publically that the current situation is unacceptable and we should confirm our undiminished resolve to do everything possible to protect and improve the Libyan patient safety. A comprehensive approach is needed which should include educational, cultural, technical, financial and legal measures. Therefore, we propose establishing an independent National Libyan Patient Safety Authority to oversee and improve patients’ safety.