What did Dialla Zacharie Coulibaly really die of? This 10-year-old boy died on August 3, 2014, at 9 a.m., at Delafontaine hospital in Saint-Denis. To date, no response has been provided. Neither judicial nor medical. Only the appointment of a new judge, who has just restarted the investigation on the basis of involuntary homicide and failure to assist a person in danger, gives the family some hope.
“In this case, health did not work, justice did not work,” says Jean-Christophe Coubris indignantly. For my clients, it’s a double punishment. » This specialist in personal injury and medical error litigation has just taken over this delicate matter.
Épinay-sur-Seine, August 2014. The silent march in tribute to Zacharie, 10 years old, who died on August 3, 2014 at Delafontaine hospital, brought together many people. LP/Jean-Gabriel Bontinck
Admitted at 5:15 a.m. to the emergency room for suspected appendicitis, Zacharie will breathe his last at 9 a.m. Doctors concluded that he died of peritonitis. A wrong diagnosis. The autopsy will show that the child suffered from myocarditis, an inflammation of the heart caused by a virus. The victim had “a heart much too big” for his young constitution. No doctor had detected this pathology.
“The chances of not dying were greater than 50%, those of recovering as well”
A twist occurs thanks to a second autopsy, carried out in October 2014. It shakes up these initial conclusions. “It does not allow us to propose a cause of death,” indicates the pathologist. These conclusions prove Zacharie’s parents right, who believe that the care of their son was not optimal.
This certainty is reinforced by a collegial medical expertise, carried out in November 2015. It identifies cascading failures. These specialists in pediatrics and cardiology are very critical of their peers and denounce “partial, late, inadequate care”. They deplore “improper medical conduct”, with terrible consequences: “The chances of not dying were greater than 50%, those of recovery as well. »
The experts agree, however, that “the clinical diagnosis was difficult”, but “there was no correct frontal chest X-ray in a semi-sitting position, which would have made it possible to discover cardiomegaly (Editor’s note: hypertrophy of the heart). Just like no electrocardiogram was done. These two examinations would have made it possible to make a diagnosis of major acute heart disease. »
The intern had placed Zacharie on a drip at 6:10 a.m. But the caregivers had all the difficulty in the world to inject the young patient. The experts are convinced: “It is obviously the filling which generated the cardiorespiratory arrest. »
They are also surprised that “between 5:15 a.m. and 8:15 a.m., no differential diagnosis was made”. “This situation required a senior to examine the patient much earlier,” they emphasize. Said senior in pediatrics was reported to Zacharie’s bedside at 6:43 a.m., “53 minutes after the intern’s arrival”, notes the college of specialists.
“We wasted five years”
This detailed expert report contradicts the administrative investigation carried out in September 2015 by the regional health agency (ARS) of Île-de-France. Responsible for detecting possible dysfunctions in the care of Zacharie, the health authority affirmed that the practitioners who examined Zacharie were irreproachable.
“The young patient benefited from continuous and attentive care from several health professionals, including doctors,” underlined the ARS. The pediatric emergency department then had qualified and competent nursing staff and satisfactory premises equipment.” For once, the teams were not overwhelmed. “The level of activity of the service and the intervention of the intern and the senior doctor were rapid,” adds the regional agency.
Since the collegial expertise, the one and only, the file has lain dormant. After the hearing of Zacharie’s parents, the instruction seems to have frozen. “This hearing was to be followed by an indictment as had been announced,” notes Mr. Coubris. But everything stopped. »
The requests filed by his predecessor remained unheeded. Until 2020, he despaired of “not having had any answers from the authorities for two years”. “We lost five years,” regrets the family’s new lawyer. And we still have three years of training. »
Last December, the new investigating judge asked the 2015 experts for “additional information”. The issue is crucial: it is a question of “confirming whether the death is indeed due to a malfunction in the hospital and poor care and not to Zacharie’s heart defect,” explains Me Coubris. “My priority,” he adds, “is to obtain an indictment from the hospital and also to have access to the medical file so that we can request compensation from the administrative court. »
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