Nekrep Case

The Nekrep Case was the court trial that followed the death of a 12-year-old boy, Bor Nekrep, due to a misdiagnosis in Slovenia in March 2008. The treating pediatrician misdiagnosed an inborn defect of the urea cycle (a very rare genetic condition). After the boy had been brought by his parents to the Paediatric Clinic in Maribor, the doctor, among other things, measured the level of ammonia in his blood and on the basis of a significantly increased level erroneously diagnosed Reye syndrome. Because of the misdiagnosis and a delay in appropriate treatment, the boy developed cerebral oedema and died eight days later.

The health condition of the boy who was before the admission to the Maribor paediatric department mainly healthy, as confirmed by parents and proved with his school report, except for a "cold", worsened despite taking antibiotics. He was admitted to the emergency department of the Pediatric Clinic in Maribor at 18:00. In an interview published in April 2009, the doctor treating him told that after she had obtained the results of the ordered laboratory tests, among them the level of ammonia, she diagnosed Reye syndrome on the basis of Nelson Textbook of Pediatrics and began to treat him. In the morning, after a consultation, the doctors there called the colleagues at the University Clinical Centre in Ljubljana and ordered his transport there. The treating physician did not directly communicate with Ljubljana.

The boy's father stated at a press conference in November 2008 that the doctors in Maribor had not discovered the elevation of ammonia. According to him, the next morning they received precise instructions for treatment by the doctors of the University Clinical Centre in Ljubljana, but did not implement them and transported the boy who had during the night lost consciousness, to Ljubljana with a "tourist transport". The boy's mother told that upon the arrival at the Ljubljana hospital, the doctors there lowered his ammonia level "only with glucose and salt to a harmless level".

As confirmed by the endocrinologist, who admitted the boy to the endocrinology department in Ljubljana, at the trial in September 2011, the boy was unconscious when he arrived there. This surprised him, because the Maribor pediatricians told him that his condition had improved. The laboratory tests that he ordered showed a significantly increased level of ammonia. The intern who accompanied the boy during the transport to Ljubljana, told that he had been unconscious already in Maribor. The transport took about an hour and a half. The emergency medical service team told that the transport was not urgent and that the transporting van was not equipped for urgent situations. This was also evident from the documentation.

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Wikipedia