In April of that year, Janneke was admitted to the emergency psychiatry department. She was specially admitted for treatment with the drug clozapine, which is considered a kind of ‘last resort’ for people who are suffering from severe mental illness.
The woman died of heart failure a month later. An examination by the Netherlands Forensic Institute (NFI) showed that she was hypersensitive to clozapine. As a result, she had developed an inflammation of her heart muscle, with fatal consequences.
Janneke should have been closely monitored after she was prescribed the medicine, but that didn’t happen. According to the court, this was due to a number of serious shortcomings in the institution. For example, the workload was too high and the actual treatment of Janneke was left to an assistant in training because the psychiatrist was on vacation.
The assistant knew too little about the possible side effects of the strong medicine. The results of blood tests were not adequately responded to. This also applied to physical complaints that Janneke developed.
The institution has failed to fulfill its duty to call in the necessary medical assistance in a timely manner, the court says. “There have been signals on several occasions that should have given rise to act differently.”
The institution has been given a conditional fine of 19,500 euros. The court deliberately does not impose an unconditional fine: “Payment of this would be at the expense of the already fragile care that is so badly needed and new clients would suffer from this.”
‘My child is not protected’
A year after her death on May 25, 2013, the family filed a report. “The GGZ had only one task: to protect Janneke’s health,” said her mother during the court case that followed. “But my child is not protected. Emergency workers have received so many signals. Janneke felt like she was dying, but nothing was done.”
Janneke’s mother also said that her daughter’s treatment was ‘degrading and degrading’. “She felt bad, but you were too bad to help her. She was in a corner on her own bed, in her own vomit and feces.”
The East Brabant court acquitted the institution in 2019 because it could not be held responsible for the mistakes of the staff. But the Court of Appeal has now ruled that the institution is indeed to blame for the course of events. That is special: it was only the second time that an entire healthcare institution was taken to court.
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