Experts on the death of Aryam (8 years old): The delay in providing medical assistance to the child and the language barrier played a role in her death... This is what the father recounted.
In the summer of 2022, an eight-year-old girl gasped for breath while lying in her father's arms in her general practitioner's office. She suffered a cardiac arrest and died. However, several factors, according to experts, suggest that her death could have been prevented.
The father sits on the hospital floor, tears streaming down his cheeks, cradling his eight-year-old daughter in his arms. Her lips are blue, and her breathing is rapid. Very rapid. Until it stops.
A severe asthma attack whose dangers could have been avoided
On August 10, 2022, at 9:47 AM, eight-year-old Ariam's heart stopped in front of her father at a medical center in Haderslev. A severe asthma attack led to cardiac arrest, costing the Syrian girl her life. However, according to experts and professionals, several aspects of the incident suggest that the death, which has not been publicly disclosed, could have been prevented.
“It is a case where there are many possibilities that could have gone differently. It is particularly unfortunate here to think that something like language barriers may have played a role,“ says Christian Weiggi, professor of multicultural medicine at Aarhus University and also a senior physician at Aarhus University Hospital.
Poor communication due to language barrier
The family is a Syrian refugee, and experts estimate that this in particular had a significant impact on the fact that things went just as wrong.
Lars Bjærum, professor of general medicine at the University of Copenhagen and a general practitioner, says: “I would say that we are dealing here with a fatal problem, which is mainly due to poor communication because of language barriers.”.
The death of the deceased girl has shocked the director of Asthma-Allergi Denmark, Anne Holm Hansen, who believes that “everything went wrong” in the treatment of eight-year-old Ariam.
“It is absolutely tragic, and it is unusual for this to happen in Denmark. We could have seen this kind of thing 60-70 years ago, because you didn't have the opportunity to do anything, but here you do. This should never happen.“.
“My daughter is about to die.”
Ariam spent the last hours of her life gasping for breath in her family home. Throughout the night, she found it difficult to breathe. At 7:30 a.m. on August 10, it was really bad.
Instead of calling 112, which could have sent an ambulance to the family's home, her father, Suhaib Al-Nassif, chose a different strategy. Nine days earlier, he had gone to the doctor with his daughter, who was diagnosed with asthma after a severe attack. During the consultation, which took place without the help of an interpreter, the father thought that his daughter's asthma was not dangerous if she took the medication directly.
Wait three and a half hours before seeing the doctor
Just one kilometer from the doctor's office, the father decided to wait for the doctor's office to open at 8 a.m. to get an appointment with the family doctor instead of calling 112. Suhaib Al-Nassif explains that during the phone conversation with the doctor's office, he did not hide the fact that he was very worried about his daughter and confirmed that she was having difficulty breathing: “My daughter is about to die. She cannot breathe,“ he says today about his conversation with the doctor's office.
According to the father, he also told the secretary that his daughter had been unable to sleep all night due to asthma. The general practitioner confirmed in the police report issued after the eight-year-old girl's death that hospital staff were aware of the girl's breathing difficulties at night.
But Aryam was not allowed to go to the front of the waiting list at the doctor's office. Instead, she got an appointment at 11:30, according to the hospital's internal appointment list. During the doctor's visit on August 1, Aryam and her father, Suhaib Al-Nassif, recorded a short video of the moment Aryam was given asthma medication through what is called an inhaler. In the following days, she continued to have difficulty breathing. On August 10, she suffered a heart attack in the same hospital.
According to Professor Christian Wiegy, Ariam should have been brought to the hospital earlier: “We are clearly talking about a child with serious breathing difficulties who is not responding adequately to treatment. So this is an urgent situation that should be taken very seriously.“ He added that the hospital’s decision to let the asthmatic girl wait for three and a half hours contradicted a guideline from the Danish Society of General Practitioners, which describes how doctors and medical secretaries should practically act if they receive a call from a patient with breathing problems. The guide works like a website, and the doctor or medical secretary must tick off the symptoms and are then told what to do. If the child has shortness of breath and asthma that “does not improve after treatment”—like Ariam—the instructions state in large red letters that it is an “acute” case. “The doctor must decide whether to call an ambulance or see the patient within an hour,” he says. Neither of these things happened that morning when Suhaib Al-Nassif sought medical help.
The medical center declined to explain why the girl was not allowed to get an appointment earlier in the day, when she was already an asthma patient at the medical center and is now also suffering from breathing problems.
Radio 4 did not name the hospital, where a patient complaints agency is currently investigating a complaint about the case. The hospital has repeatedly declined to comment on the criticism, but the family agreed to speak about the procedure to Radio 4.
Delay in providing urgent care
Indeed, on 23/09, Suhaib Al-Nassif called the doctor's office for the second time when his daughter's condition worsened and he no longer dared to take responsibility for her life. So he told the medical secretary on the other end of the phone that his daughter needed help more quickly and that he would come before the agreed-upon time. However, the doctor's office secretary told the Patient Complaints Agency: "At no point did I feel that it was urgent.".
But in the hospital's internal appointment booking, the secretary writes that the family "comes early, as they say it is urgent with breathing.".
Christian Wegge believes that both of the secretary's statements may be true in themselves, however, this means that she did not take her father's concerns seriously, according to his assessment: "The father's concern regarding dealing with a child suffering from a severe, serious, and terminal illness was not taken seriously.".
With blue lips and heavy breathing, according to the father, so much so that it can be heard from a distance, Suhaib Al-Nassif carries his daughter through the door to the doctor's consultation room, where the doctor examines her, but the girl is not attended to directly. Instead, the father is asked to communicate with the secretary. He places his daughter on two chairs in the waiting room and rushes to the hospital reception.
Ariam: “I am dying”
“I went to the secretary, and then my daughter came crawling on the floor. She said, “Help me, Dad.” Suhaib Al-Nisf says, ‘I’m dying.’ He finds it difficult to talk about the day his daughter had a cardiac arrest at the doctor’s office…”.
Although the daughter was unresponsive at the time, requiring her father to take her to the doctor's office beforehand, a review of the procedure shows that at least seven minutes passed from the doctor's arrival to begin treating the girl. She received medication to prevent asthma attacks via an inhaler, and a mask was placed over her mouth and nose. Ariam managed to take a few puffs of the medication, but it was too late. Seconds later, eight-year-old Ariam suffered cardiac arrest.
Resuscitation attempts followed by death
Then things move quickly; two other doctors and a nurse run in and try to resuscitate her. Patients in the waiting room are asked to leave the doctor's office, and the medical secretary calls the emergency center.
Four minutes later, an ambulance arrived. Shortly after, a medical van also arrived. Between 25 and 40 minutes passed before Ariam's heart started beating again. When it did, the ambulance, escorted by police, transported her to Odense University Hospital, but it soon became clear that treatment was hopeless. The many minutes without oxygen had put so much pressure on her brain that there was nothing more that could be done.
Aryam's death was officially announced three days later – on August 13 at 8:03 AM.
Father's feeling
Suhaib Al-Nassif feels that he has let him down and that his daughter did not get the help she needed.
“"It's terrible that this is happening here in Denmark. There's a girl dying and no one is helping her.".
Nine days ago, the father took his daughter to the doctor's office in Haderslev for the first time. He says he was worried about her breathing difficulties. Ariam arrived with what experts say is a severe asthma attack. She is gasping for breath, making characteristic asthma sounds, wheezing and whistling in her lungs, and experiencing what is known as chest pulling.
The girl's medical record shows that during the consultation on August 1st, Ariam developed "asthma".
Suhaib Al-Nassif says it was a bad experience with the general practitioner, as he felt ignored. The father states that the doctor did not tell him what the family should do if, for example, his daughter's medication didn't work or if she had another asthma attack.
Instead, according to the father, the general practitioner contacted the eight-year-old girl directly, who also received treatment during the initial meeting, a prescription for asthma medication, and a follow-up appointment more than three weeks later. Professor Lars Bjerøm considers the wait far too long.
Lars Bjerrum says: “Especially when it comes to a patient and family where there are language challenges, I probably don’t want to wait three weeks to see how things go.”.
When is it appropriate to follow up?
”During the first week. I would say the next day or the next two days,“ says the professor, who believes that Ariam could have been helped if she had actually been admitted to the children’s ward on August 1.
“What could have been a reason for choosing this solution is that you didn’t know the family beforehand and therefore didn’t know anything about whether they had asthma and were used to dealing with it, and this was the first time you were seeing them, so you didn’t really know how familiar they were with the Danish healthcare system, and whether they knew what to do if things went wrong,“ says Lars Bjærum.
During her doctor's visit on August 1st, Ariam was prescribed an inhaler. She used it repeatedly until her last doctor's visit on August 10th. But this is precisely what the experts are wondering about. Ariam is only being treated with medication that relieves symptoms, not with adrenocorticotropic hormone (ACTH), which prevents new asthma attacks.
Professor Christian Wegge from Aarhus University assesses: “It was very possible to save lives if such treatment had been started.”.
But Ariam ends up in intensive care. Her brain is dead, and she's connected to machines that are artificially keeping her alive.
The professor wonders
Suhaib Al-Nassif and his wife speak very little Danish. Given this background, Radio4 also hired an interpreter for the interviews. However, neither for the consultation on August 1st nor in the following days did the medical center book an interpreter, so they were certain the family understood how their daughter's asthma should be treated.
Suhaib Al-Nassif says: “If there were a translator, it would be a great advantage.” .
Professor Christian Wiegge from Aarhus University questions why an interpreter isn't used. According to him, it's crucial that the doctor and patient understand each other.
“Language is extremely central. Communicating with patients is by far our most important clinical tool,“ says Christian Weiss.
Due to language barriers, communication between Suhaib Al-Nassif and the girl’s doctor also appears to end in an alternative way, with the doctor prescribing an inhaler for the girl on August 1.
Suhaib Al-Nassif explains that during the consultation, he had to pull out his phone so that the doctor could use it to show Google images of the asthma inhaler that the Syrian family had to pick up from the pharmacy.
He showed us how to use it after she asked me what it was. I took out my mobile phone so he could type it into Google so I could see what it was,“ says Suhaib Al-Nassif, who, despite the pictures, is still unsure how many times he should give his daughter the new medicine.
“Then he said that maybe they would have to explain it at the pharmacy. I couldn’t understand what it was because there was nothing tangible that I could see,“ he says.
A former neighbor of the family describes Ariam as a girl who was always loving and wanted to hug the people she knew. Photo: Private
A former neighbor of the family describes Ariam as a girl who was always loving and wanted to hug the people she knew. Photo: Private
The doctor's responsibility to ensure understanding
According to Professor Christian Wegge, the medical center should have received assistance with simultaneous interpretation regarding the doctor's visit where Ariam was diagnosed with asthma.
“Given the urgent need for information here, it was obviously appropriate to make sure an appointment was booked with an interpreter – perhaps as early as the next day – so that the parents could understand what was going on here and what the treatment involved. Also, because a child with relatively severe asthma has been prescribed here,“ says Christian Weggi.
In a consultation held in 2020, the then Minister of Health, Magnus Heunicke (S), stated that in matters concerning children, the doctor always bears the responsibility of ensuring that parents understand the doctor. Therefore, it is also up to the doctor to have an interpreter available if necessary.
But doctors in the municipality of Haderslev don't do that. That's why it wasn't translated into Arabic either, when the doctor explains to parents how their daughter's new inhaler works, what type of asthma she has, and how to manage the condition.
According to Suhaib Al-Nassif, the doctor only addresses eight-year-old Ariam, who speaks Danish.
“He didn’t speak to me at all. He didn’t even look at me. He only spoke to my daughter,“ said Suhaib Al-Nassif.
The Danish Patient Safety Agency does not consider there to be a risk to future patient safety at the medical center. Similarly, the police have concluded their investigation into the death. However, a complaint remains with the Patient Complaints Agency, which must determine whether the quality of treatment in the eight-year-old girl's case met medical standards.
Despite repeated attempts to obtain a comment from the hospital in question, neither the Medical Association nor the Association of Practitioners wished to be interviewed about the specific case. The administration of the Southern Denmark region also declined to comment, according to Radio4.
