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Va. Health Facility Blamed in Death

May 21, 1999

RICHMOND, Va. (AP) _ Shoddy medical care and poor communication between nurses and doctors were to blame for the death of a patient at a state-run mental health institute, two confidential reports said.

Skander Najar died June 8 from an inflamed, bleeding pancreas while he was a patient at the Northern Virginia Mental Health Institute. Two days earlier, he was vomiting and showing other symptoms, but nurses’ notes show the on-call doctor who was notified put off seeing him until the next morning.

Najar, 26, didn’t receive emergency treatment until his mother, Hanni Najar, arranged his transfer to neighboring Fairfax Hospital at a nurse’s urging, an internal report by the institute said. The Associated Press obtained a copy of the report.

Fairfax Hospital staff fought for 24 hours to save Najar, but couldn’t.

The internal investigation said Najar’s death was caused by human error, specifically ``inadequate physical assessment, documentation and communication of the patient’s changing clinical condition″ by the institute’s medical staff. It said nurses believed they would be yelled at by on-call physicians who believed they were receiving too many calls.

A consultant for the state attorney general’s office drew similar conclusions in a separate review. ``The information in the record indicates that on on-call M.D. should have ensured immediate medical evaluation,″ the consultant, psychiatry professor Catherine A. Leslie, wrote.

The U.S. Justice Department has been investigating negligence, abuse and deaths of patients in Virginia’s public mental institutions since 1990, and the Northern Virginia institute is still under investigation.

Half of the psychiatrists at the institute, including the on-call doctor, lost their jobs after Najar’s death. The institute has adopted policies to improve basic patient care and staff communication that include having an on-site doctor 24 hours a day, seven days a week, and the state mental health system has been overhauled.

Ms. Najar said the reports confirmed her fears about her son’s death.

``I had already come to the conclusion that there were problems at the institute, but I wasn’t fully aware of the extent of the problems,″ she said.

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