The Jalisco State Human Rights Commission (CEDHJ) andissued its recommendation 16/2022 on the alleged institutional responsibility of the Decentralized Public Organization (OPD) Jalisco Health Services (SSJ) and the Civil Hospital of Guadalajaraabout the case of a girl who died after being bitten by a violinist spider and not having access to the antidote.
The doctors in the emergency area of the pediatric area of the Civil Hospital, suspecting the bite, put her under observation and surveillance, since poisoning (loxoscelism) can occur up to 48 hours after the bite.
Some symptoms were advanced, and the deterioration appeared 38 hours after the insect bite. Clinical and laboratory evidence was as follows: hemolysis, acute kidney injury, pulmonary hemorrhage, acute liver failure, and hyperdynamic shock.
After 50 hours and as there was no improvement, the patient entered therapy for probable visceral cutaneous loxoscelism, without being able to obtain the antidote against the condition.
After 68 hours of admission to the hospital, the minor presented cardiorespiratory arrest without response to advanced cardiopulmonary resuscitation maneuvers, and died at 11:30 p.m. on September 22, 2017 with final diagnoses of pulmonary hemorrhage, coagulation, and spider venom intoxication.
From the investigations carried out by the CEDHJ, it was possible to conclude that no situation of imprudence, negligence or inexperience was found in the actions of the medical personnel who intervened in the care of the little girl. The foregoing, because it considered that they deployed all the necessary means for the healing of the patient, which were in accordance with the lex artis described in the literature consulted by the Ombudsman.
The Commission found in the Clinical Practice Guideline SSA-523-11 “Diagnosis and Treatment of Venomous Spider Bite” for poisoning there are two types of antidotes in Argentina, Peru, Brazil and Mexico, information on antivenom was requested and they indicated that in the country no longer produced since 2014.
And furthermore, the antivenom was not sought in other countries, thus violating the human rights to health, life and the rights of children of the injured minor, giving rise to institutional responsibility.
The CEDHJ issued the following recommendations:
To the directors of OPD HCG and OPD SSJ
Instruct the personnel that is competent, within the administrations under their charge, so that in a joint, coordinated and solidary manner, the reparation and integral attention of the damage in favor of the victims is carried out, Therefore, they must grant all the measures of restitution, rehabilitation, compensation, satisfaction and guarantees of non-repetition that are appropriate.. Issue instructions so that specialized personnel provide the necessary thanatological, psychological or psychiatric care to the indirect victims of the events.
In particular, to the general director of the OPD Civil Hospital of Guadalajara
Order an investigation of the case through the Quality area of said body, and from the result, proposals are drawn up that make possible the continuous improvement of the quality of medical care. Likewise, and as part of its attributions, programs are incorporated for the care and management of adverse events such as the one documented hereaccording to the following steps as a minimum:
-Promote a cultural change through the development of disciplined thinking, leading to systematic research and analysis of the causes of adverse events and organized work for their prevention.
-That there is sufficient supervision to guarantee compliance with patient safety measures and the application of current regulations in the care process.
– Disseminate knowledge of what is documented here, its causes and prevention strategies, which must include a reengineering of administrative processes so that medical service users have complete and properly integrated clinical records.
-Train staff to fulfill their responsibilities and improve their performance.