Bahamas Patient Advocacy

The new Coroner’s Court law: Investigating and Preventing Deaths in The Bahamas

The government’s draft Coroner’s Bill makes welcome changes to the archaic 1909 Coroners Act that currently applies in the Bahamas.

The intent of the proposed law is to help prevent “reportable” deaths and promote justice. A primary purpose of the Bill is to reduce “the occurrence of other deaths in circumstances similar to those in which a death occurred.” 

It gives the Coroner (a specialist magistrate) the power to report preventable deaths to investigating authorities:  “if satisfied that the public interest would be served.” This process has the potential to make changes in the public interest that will promote a safer society. But other institutions will have to perform if that potential is to be achieved.

For example, we will need a Hospitals Board and a Medical Council able and willing to investigate any Coroner’s report on a preventable death in healthcare services. In other words, we can no longer avoid making healthcare facilities accountable for the patients who are in their care.

Excerpt from Hospitals & Healthcare Facilities Board 2007 Annual Report

This is one of only two annual reports the Board has produced since it was created in 1998, although it is required by law to report to parliament every year. This report was produced after adverse publicity in the press. Although it was tabled in parliament in December 2008 it is currently unavailable to the public. This issue was discussed at length in the Tribune and on Bahama Pundit.

"In July 2004 Ms Leandra Esfakis complained in writing to the Board that there was contributory negligence in the death of her brother, Christopher Esfakis, a burns patient at Doctors Hospital. She continues to write letters to the Board and contributes articles to the newspapers demanding essentially the following:

A Response to Alesha Hart on the 'Deafening National Silence'

(This letter by Leandra Esfakis was published in the Tribune recently in response to an article by Alesha Hart complaining about public indifference to the victims of crime.)

Dear Ms Hart:

Your article of last week speaks eloquently of the deafening national silence. You say that by our silence, and failure to attend the candlelight ceremony on June 15, to honour the victims of crime, we disrespected the memory of fallen victims and tomorrow's victims as well.

A candlelight ceremony is a symbol of sorrow, respect, and hope  - for an effective response to the issues which create victims of crime. And poor attendance would indicate that perhaps we as a people are not caring enough to step outside our comfort zones, and honour those who have fallen.

I do believe, however, that we are caring. But what do we care about? And do we have the conviction and courage to defend what we should care about - at least our lives?  Or is that we have no expectation of a better tomorrow, because we know that we put into positions of power, persons who are no more than a reflection our own weaknesses, and when tested are unable to rise above those weaknesses. 

And so I would like to offer an answer to the last haunting question you raised: "I wonder who will speak clearly if something happens to me?"

Watching out for the Watchdog—the Coroner's Court in the Bahamas 100 Years on

 Over the eight centuries since the office was established in England, the role of  coroner has evolved from tax collection to an independent judicial office that investigates sudden, violent or unnatural deaths.

In 1988 the British changed the coroner's act so that no criminal charges could result as a consequence of evidence produced at an inquest. However, the notable case of Dr. Harold Shipman (who was convicted of murdering 15 patients) led to three public inquiries that forced a review of this law.

But in the Bahamas there has been no review, no amendments, and no regulations or rules made under our coroner's act since it was passed in 1909.

And how well does that century-old law enable our coroner to meet the changing needs of a rapidly developing society, and provide service to the public in general, and the bereaved in particular?

When is a hospital, a Hospital?

The 2007 annual report of the Hospitals Board tabled in Parliament last December raises some important public interest issues.                           

One of those issues is whether the Hospitals Board has the ability to function as a regulator of private hospitals and clinics under the Hospital and Health Care Facilities Act, 1998.

For example, the Hospitals Board has a duty under the Act to investigate a complaint into the “management, diagnosis, and treatment” of a patient in a hospital or clinic licensed by the Hospitals Board.

But it seems the Hospitals Board’s view is that it licenses the building and its facilities, and not the quality of health care services provided.   The Act itself defines a hospital as "a building where beds are available for the admission of persons requiring treatment for any sickness”.

Experts say this description is not adequate. It does not require a central legal entity that is responsible and accountable for all medical services provided under its roof. That structure, according to advisors, would be in the best interest of the community for the obvious reasons of safety and ethics. There is a disconnect here which can adversely affect quality assurance in medical treatment.   

Transcript of Chief Justice's Ruling in Dr James Iferenta v Coroner William Campbell

The coroner's court is neither a civil nor a criminal court, and the rules of procedure for those courts do not apply. The coroner's court is an inquiry into the circumstances of a death, and not an adversarial proceeding. The coroner's court is a court of record, and those records are public.

Legal authorities indicate that the coroner has discretion in determining what verdicts are to be left to the jury. There is no obligation on the coroner to put every possible verdict before the jury - only those  supported by the main thrust of the evidence.  According to one senior lawyer, the coroner is the alpha and omega of the coroner's court.

Judicial review of an inquest is generally applied for because one party thinks other verdicts should have been left to the jury, and/or that the verdict reached was not a reasonable one given the evidence.

Legal authorities also indicate that on an application for judicial review of an inquest, the judge would examine the evidence given at the inquest and determine whether it supported the verdict given, or specify what other verdicts - supported by the evidence - ought to have been left to the jury, and give his reasons.   

In the application for judicial review of the Esfakis inquest by Dr. James Iferenta, the Chief Justice did not review any evidence. The Chief Justice made a determination of principle that the coroner could not leave a single verdict to the jury.

This is a precedent which now binds the coroner's court. The effect is that in every future inquest the coroner will be obliged to leave more than one verdict to the jury.

As of the end of November, 2008 the chief justice had given no written reasons for his ruling, and had not signed the order quashing the Esfakis inquest. What follows is a transcript of the unsigned ruling:

"The applicants in this case were given leave to move for judicial review by way of an order of certiorari quashing the summing-up and/or direction given by the coroner to a jury which returned a verdict, which verdict is in the prescribed form under the Coroner's Act, Chapter 56.

The challenge as framed and advanced by counsel for the Applicants raised a number of issues which would have invited the court's consideration and considered determination thereof, save for the fact which starkly appears from the record that after this extensive hearing involving a large number of witnesses over several adjournments as indicated in the juror's inquisition, the Coroner began his directions to the jury in this manner:

Advice on Patients Rights and Medical Care

This website aims to inform patients of their rights, and urge them to be alert and pro-active in their health care. We welcome constructive comments alerting readers to medical issues in the Bahamas or elsewhere.

However, we cannot accept comments that would raise issues of libel against any individual. The only defense to libel is to prove the truth of the comment made. This could result in a court action, and expert witnesses would have to attend to give evidence as to the truth of the comment.

Petition on Accountability in Bahamian Healthcare

Do you believe that Bahamian healthcare services and patient survival rates can be improved?

Then join in sending the message to our government, that the Hospitals and HealthCare Facilities Board needs to do its job or be replaced by a truly independent and impartial healthcare commission that will protect the interests and lives of the Bahamian people.

You can sign the petition online here www.petitiononline.com/lesfakis/petition-sign.html?

A Similar Coroner's Verdict in the UK—With a Very Different Response

A British coroner ruled recently that  a nurse's death from massive bleeding after she gave birth by caesarean in her own hospital resulted from neglect and failings in the maternity unit.

Last month, the coroner recorded that the woman's death three years ago was "contributed by neglect" and there had been "ongoing failures" in her maternity care at Northwick Park Hospital in London.

Her death was the tenth at the hospital's maternity unit in three years, and has led to an investigation by the NHS watchdog, the Healthcare Commission.

A Summary of the Esfakis Case

Christopher Esfakis, 42, was the son of the late Dr Andrew Esfakis, a leading Nassau doctor of Greek descent, and Violet Esfakis, a nurse.

On Saturday, April 20 2002 he admitted himself to Doctors Hospital, suffering from burns to 25 per cent of his body due to a household accident. He walked into the emergency room without any physical assistance.

He was assessed as having sustained an inhalation injury and a treatment programme was put in place by Dr. James Iferenta, his primary care physician. Mr Esfakis' chances of survival and full recovery were put at over 90 per cent.

Sixty-six hours later he was dead. The pathologist noted the cause of death as a) cardio-respiratory arrest, acute pulmonary congestion and edema; and b) airway obstruction due to inhalation injury. His body weight at the time of death was 190 pounds due to excessive fluid intake. When he was admitted he weighed 130 pounds.

Magistrate William Campbell presided over an inquest into Esfakis' death which began in April 2007. About 20 witnesses gave evidence, and the magistrate's verdict was delivered on February 29 2008. The verdict listed the cause of death as "natural causes with a substantive contribution of neglect."

In April 2005 the deceased's sister, lawyer Leandra Esfakis, filed a complaint with the Healthcare Facilities Board. which licenses local hospitals.

The complaint has been ignored under three successive ministers of health, although the law provides that:

1. The Board can select experts to investigate a complaint.
2. The experts report back to the Board.
3. The Board can made recommendations to the Hospital on what it need to do in order to renew its license.

In May, 2008 Ms Esfakis filed a complaint with the Bahamas Medical Council, which governs local doctors.

A civil lawsuit is also pending against Doctors Hospital.