Insufficient control at various levels led to the switch of babies in "Sheinovo" hospital - inspection results

Insufficient control at various levels is the main thing that led to the switch of babies in Sofia’s “Sheinovo” hospital, the Executive Director of the Medical Supervision Agency, Prof. Dr. Rossen Kolarov, told a briefing to the media on January 9. The agency's inspection found violations of at least four texts of the medical standard on neonatology.

"Somewhere there is insufficient control, although the control is four-stage. Accordingly, the midwife in the ward who puts on the wrist bands, the neonatologist who controls the process, when they are given to the mother, the wrists bands still have to be compared, when the children are discharged from the hospital it is mandatory to check the numbers. Somewhere along the line this check on the match of the numbers on the bracelet of the mother and the baby was not done. Undoubtedly there is human error," said Prof. Dr. Rossen Kolarov.

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The report with the results of the inspection describes omissions, inaccuracies and non-compliance with certain requirements in the regulations, which is why administrative offence acts will be issued.

Mandatory guidelines have also been issued. The inspection report will also be sent to the investigating authorities, where the case is also under investigation.

An inspection of all obstetrics and gynaecology wards in the country, which are more than 130, has been launched to ensure that no similar violations are committed. Risk-based supervision will also be introduced - those risk points that are important will be assessed to prevent such violations.

Medical supervisors have checked medical records, but investigating authorities need to establish exactly how the switching of the babies happened.

The inspection of the Medical Supervision was conducted in the period between 21 December 2022 and 4 January 2023. The report was handed to the hospital and submitted to the Minister of Health. A letter has also been sent to the Child Protection Agency.

Earlier today, the director of “Sheinovo” hospital, Dr. Rumen Velev, said that new control mechanisms were being considered. The hospital is exploring the option of introducing a new system that automatically generates special bracelets with barcodes. This would rule out the possibility of subjective error.

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