Doctors and nurses who attended to Stephen Mangion did nothing wrong and should not face criminal prosecution for his death, a magisterial inquiry has concluded.
An inquiry by Magistrate Joe Mifsud found no evidence of intent, negligence or delay by medical staff assisting Mangion. It concludes that the doctors and nurses on duty that night are not liable for criminal prosecution.
Times of Malta is informed that the 500-page report also calls for the reintroduction of imprisonment for defamation and the intentional spread of misinformation regarding third parties.
Mangion, a 55-year-old resident of Valletta and a former police officer, died from an aortic dissection after collapsing in the hospital’s emergency waiting room.
His sudden death sparked outrage on social media with claims that he had waited for hours despite reporting chest pains, first at the Floriana health centre and later at Mater Dei Hospital.
The inquiry, conducted with the assistance of several court experts, established that Mangion had first experienced symptoms at 4am but delayed seeking medical help for 15 hours.
Despite advice from family and friends throughout the day, Mangion initially chose not to seek medical assistance at the Floriana health centre.
The inquiry revealed that Mangion had not been taking his prescribed medication for high blood pressure. His symptoms were atypical, making it difficult for the medical team to diagnose the aortic dissection that led to his death.
Sources privy to the inquiry told Times of Malta that the healthcare providers did everything possible to save Mangion's life.
He underwent three ECGs, one at Floriana health centre and two at Mater Dei, none of which indicated that he was at immediate risk of a heart attack.
In his report, the magistrate stated that, given the circumstances, the medical staff could not have reasonably foreseen Mangion’s condition.
A court expert’s report, quoted by the magisterial report, shows that between 7:15pm and 7:46pm, a total of 13 ambulances were in service and none could be dispatched immediately to transport Mangion from Floriana health centre to Mater Dei hospital.
It was then that Donald Cassar, a friend and a nurse who had been with Mangion all along, offered to drive him to Mater Dei.
The inquiry also shows that on that day, 251 patients visited the Emergency department, with more than half classified as urgent.
The department was particularly busy between 7pm and 9pm, during which 22 urgent cases were handled, averaging one case every 15 minutes. Eight of these patients complained of chest pains.
The report further indicates that between 8pm and 10pm, 41 new patients registered at the Emergency Department, 25 of whom, like Stephen Mangion, were classified as urgent.
Fake profile
Court sources told Times of Malta that the inquiry also addressed the public controversy surrounding the case, dismissing allegations spread on social media.
These claims, which started from a fake profile named Manuel Debono, were described as having caused "unnecessary fear and alarm."
Magistrate Mifsud emphasised that the claims were unfounded and lacked any basis in eyewitness testimony or documentary evidence.
In his conclusions, Magistrate Mifsud called for stronger protection to safeguard the reputations of public health workers when false claims are made.
He also proposed reconsidering the reintroduction of Article 252 of the Criminal Code, which previously prescribed imprisonment and fines for those convicted of intentional defamation. The provision was removed when criminal libel was abolished in 2018.
Police sources told Times of Malta that the report called upon the police to warn certain individuals identified by a cybercrime expert, to refrain from commenting publicly in tragic circumstances before the facts are fully known.
It is understood that the magistrate advised that the inquiry be made public to dispel the public alarm caused by the allegations.
The magistrate praised the family for publicly condemning those who used the tragic event to spread misinformation.
Copies of the report were handed to the Attorney General’s Office, Health Minister Jo Etienne Abela, the health ministry’s permanent secretary Joseph Chetcuti, and Police Commissioner Angelo Gafà.
Timeline of August 27, 2024
4am Stephen Mangion complains of chest pains and heartburn.
7:45pm Mangion texts his former wife to ask for information about pills for heartburn.
8am Mangion communicates with his friend Donald Cassar. Cassar suggests, twice, that Mangion should go to the Floriana health centre. Mangion also refuses similar advice from his children.
4.30pm Mangion texts his daughter to tell her that the pain has increased and that Cassar had offered to accompany him to the Floriana health centre.
6pm Cassar visits Mangion at home. He is still in pain but refuses to go the health centre. He instead calls a telemedicine service and is attended by Dr Martin Mallia, who suggests that Mangion should go to the Floriana health centre.
7:07pm CCTV footage shows Mangion arriving at the Floriana health centre. He is driven by his friend and nurse Donald Cassar.
7.10pm Within a few minutes, after registering, Mangion is examined by Dr Andre Abela and undergoes an ECG.
7:37pm The doctor calls Mater Dei’s emergency department requesting an ambulance for Mangion. The doctor is told to keep an eye on Mangion, because no ambulances are available but one will be sent as soon as possible.
7:44pm A second phone call cancels the request for an ambulance, because Mangion’s friend has offered to drive him to Mater Dei.
7.44pm CCTV footage shows Mangion walking out of the Floriana health centre and settling into the passenger’s seat of his friend’s car.
7:47pm CCTV footage shows the car moving away from the car park.
7:58pm Mangion, once again accompanied by Cassar, walks into the Mater Dei Emergency department and registers his name.
8pm Mangion reaches the waiting room of the Emergency department.
8.16pm Mangion is assessed at triage by nurse Nicole Schembri.
8:19pm Mangion is given a second ECG.
8:22pm Mangion walks out of triage and sits in a location that is not covered by CCTV. All the while he is accompanied by Cassar.
8:24pm A nurse approaches Mangion and asks him to follow her.
8:28pm A third ECG is administered to Mangion. None of the ECGs show that Mangion was at imminent risk of a heart attack, but repeated tests show that blood pressure is high.
8:29pm Mangion returns to the seat he had previously occupied. He remains there for an hour and fourteen minutes. During this time he stands up multiple times and makes phone calls.
9:15pm Ronald Mangion, Stephen’s brother, replaces Donald Cassar.
10:13pm Mangion speaks to two different nurses including Elisa Vella, who hands him two paracetamol tablets.
10:18pm Mangion returns to his seat.
10.22pm A man notices Mangion appearing unwell and reaches out to him. Several nurses converge on the scene.
10.25pm Mangion collapses. Dr Josef Mifsud intervenes. Mangion is placed on a stretcher and is taken inside. CPR is performed before the resuscitation room is reached. Dr Pierre Agius and Dr Mark Abela lend a helping hand.
11pm Mangion is certified dead by Dr Josef Mifsud.