Patient identity mix-up at Celje Hospital: second nurse denies guilt
Nurse Marija Klinc denied guilt at Žalec District Court for the mix-up of two patients' identities at SB Celje in 2022. The trial will begin on 25 November.
Second accused nurse denies guilt for patient mix-up in Celje
Marija Klinc, a nurse at the Celje Emergency Centre, denied guilt at today's hearing at Žalec District Court for negligent performance of work duties. According to Žurnal24, she did so in the same manner as her co-defendant Teja Žarn Kozole, who denied guilt at a preliminary hearing in September.
Prosecutor Davorina Hovnik is convinced that both nurses are responsible for the mix-up of two patients' identities from the Trubarjev Home for the Elderly in Loka pri Zidanem Mostu, which occurred more than four years ago.
What happened on 7 September 2022
On that day, the care home called the Sevnica health centre early in the afternoon and requested transport of two residents to Celje General Hospital — one had pneumonia, the other had a urinary tract infection. Both were admitted to the hospital shortly before 5 p.m., but neither had an identification wristband on their arm. Staff from the health centre are said to have handed over the documentation separately from the patients, and both residents were reportedly not communicative.
One of them died 37 hours after admission. His relatives were informed of his death on 9 September. Four days later, on 13 September, the family of the second resident learned that he would return to Trubarjev Home — but when he arrived the next day, staff discovered that they had brought a resident with the wrong name.
On 14 September itself, relatives buried the wrong deceased — that evening on the same day they learned that their father was actually alive.
Minister: "The story is shocking and incredible"
The then health minister Danijel Bešič Loredan immediately convened a press conference. "The story is shocking, difficult and actually incredible," he said. He emphasised that the son was not told that his supposed father was critically ill, but was merely informed that he had died, and was not offered the opportunity to say farewell in the mortuary. "If they had let him go to him, he would have immediately seen that the deceased was not his father," the minister added.
Bešič Loredan apologised to the relatives and offered them assistance in dealing with bureaucratic matters. According to reports in Slovenske novice, he expressed hope that they would "at least mitigate to some extent the emotional distress and upset of both sons, who learned of their father's death in this manner, after he had been cremated and buried in a grave under another person's name."
Following the incident, both the hospital director Aleksander Svetelšek, who had been in post for only six months, and the chief medical director Franc Vindišar resigned.
Internal oversight did not identify a direct perpetrator
Internal professional oversight and systems oversight at SB Celje showed that the identity mix-up occurred in the emergency centre triage. However, the commission did not identify a direct perpetrator: "During the oversight, it identified several systems shortcomings, which most likely, as a series of unfortunate circumstances, led to the identity mix-up between the patients."
The death of the first patient was not the result of incorrect therapy — both were treated on the basis of the clinical presentation of their illnesses regardless of documentation. A few days later, the second patient also died in another hospital.
Defence counsel proposes nursing expert
Lawyer Tjaša Godunc, counsel for 58-year-old Marija Klinc, who earns 1,200 euros per month and is trained as a general nurse while performing the duties of a senior nurse, proposed to the court the appointment of a nursing expert. This expert should assess whether her client acted in accordance with professional standards, nursing doctrine and triage protocols of the Manchester Triage System (MTS) — a standardised tool for classifying patients according to the degree of clinical urgency.
"To find the answer to whether the defendant acted in accordance with the MTS and whether she can be accused of neglecting careful performance of work and conscious negligent behaviour, an independent nursing expert is required," Godunc explained. She added that in the SB Celje commission during systems oversight there were only doctors, not nursing practitioners, although procedures in this field were being discussed.
Defence argument of co-defendant's counsel: she was not a public official
The counsel for Teja Žarn Kozole, lawyer Boštjan Podgoršek, highlighted a key argument in his client's favour back in September — that at the time of the alleged criminal act she was not a public official, as required by Article 258 of the Criminal Code. Žarn Kozole is said to have worked at Sevnica Health Centre only through a student placement and completed just 437 hours in 2022, while the regular establishment was around 2,080 hours. Furthermore, she reportedly did not complete the mandatory internship following completion of secondary school in that period.
"I propose to the court that it halt the criminal proceedings against her," Podgoršek said. Prosecutor Hovnik opposed this and insisted that it was entirely clear from the charge proposal why Žarn Kozole could be regarded as a public official. At the same time, she agreed with the proposal to appoint a nursing expert.
The full indictment will be presented in public for the first time at the start of the trial, which is scheduled for 25 November. What exactly happened that September night at Celje General Hospital thus remains without a final answer for now.
Source: Žurnal24