*MEDICAL HOMICIDE AND EXTREME NEGLIGENCE

Iván Darío González ÁlvarezCarolina Hernández RiverosAndrea Modera Hernández

February/10 XI Semester

CONTENTS

Questions ?

Discussion

Results

Case 1 Case 2 Case 3 Case 4 Case 5

Materials and Methods

Introduction

• Cause of Death– Etiologically specific disease and/or injury

responsible for initiating the lethal sequence of events.

• Proximate Cause– In a natural and continuous sequence, produces the

fatality.

INTRODUCTION

Deaths During Medical Care

Natural Death

Death due to Therapeutic Complication

Accidental Death

NYC Office of chief Medical Examiner and Department of Forensic Medicine

• Natural Death:– Those completely due to natural disease

• Therapeutic Complications:– Those due to predictable complications

of appropriate medical therapy

• Accidents in a Medical Setting:– Deaths due to unanticipated

complications and/or inappropriate therapies

• Homicide:– Death at the hand of another person or

due to hostile or illegal act or inaction of another one.

• Criminal Neglect:– Failure of the custodian to provide the

minimum of acceptable care to the dependent.

Manslaughter Reckless homicide

Medically Related Deaths

Reckless Endangerment

Deaths Certified as Homicide

Criminally Prosecuted

• Manslaughter:– Medical caregiver intentionally causes the

death of the patient

• Reckless endangerment– Death is due to treatment by an

unlicensed fraud or quack.

• Reckless homicide– This circumstance involves a gross and

wanton disregard for the well-being of the patient and is the most controversial in the medical community.

MAT

ERIA

LS A

ND

MET

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MATERIALS AND METHODS

• *NYCOME investigates:

– Unexpected, violent and suspicious deaths in NYC

– Deaths that occur during diagnostic or therapeutic procedures must be reported

*NYC Office of chief Medical Examiner and Department of Forensic Medicine

• 2005 Manners of Death:

– 3921 Natural– 1999 Accident– 588 Homicide– 488 Suicide– 481 Therapeutic complications– 304 undetermined

• The autopsy, medical and investigations reports of five deaths were reviewed.

• All of them occurred in NYC

RESU

LTS

ELECTIVE TERMINATION OF PREGNANCY DEATH WITHANESTHESIA COMPLICATION

• 30 year old woman– Elective termination of a 7 weeks gestation. – The patient underwent general anesthesia

(Methohexital)– Developed respiratory arrest at the recovery

room– Resuscitation efforts

• 7 months in a persistent vegetative state

• Complications:– Pulmonary and urinary tract infectionsPatient died 5 years later.

• The decedent received suboptimal care and inadequate postoperative supervision.

• Cause of death: “Complications of anoxic/ischemic

encephalopathy due to respiratory arrest following elective abortion at 7 weeks

gestation”

• Death certificate stated: Extreme medical negligence

• Manner of death:Homicide.

“THERAPEUTIC” CARBON DIOXIDE ADMINISTRATION

• 39 year old woman

– Administered O2, N2, and CO2 twice a week.

– To induce convulsions and unconsciousness.

– The decedent become violent and vomited.

– During a session the decedent went into cardiac

arrest.

• Resuscitated and transported to a hospital.

• Remained in a persistent vegetative state and died 20 days later.

• In the physician's apartment was found unlabeled gas tanks, gauges, and hoses.

• Cause of death: “Complications of anoxic encephalopathy due to

inhalation of medically administered carbon dioxide and nitrous oxide”

• Death certificate stated: extreme medical negligence.

• Manner of death:Homicide.

ESTHETICIAN ANESTHESIA COMPLICATION

• 35 year old woman– Undergoing laser treatment by a dermatologist for

oral hairy leukoplakia.– After six months of attending that procedure,

patient was reported missing .– Treating “physician” was unlicensed and had never

attended medical school. – Performed laser procedures only ment to a

licensed physician

• Autopsy: markedly decomposed with no injuries or anatomic cause of death.

• Toxicology: barbiturates, phenylpropanolamine, phenethylamine and lidocaine.

Expert testimony stated that she died due to lidocaine poisoning

• Manner of death: Homicide.

PERITONEAL DIALYSIS CATHETER USED AS FEEDING TUBE

• 78 year old woman who lived in a nursing home.– Renal disease: hypertensive cardiovascular

disease.– Physician ordered feeding tube solutions to be

administered through her peritoneal dialysis catheter.

– After 2 days, a nurse noted shortness of breath, abdominal distension, and vomiting.

• The attending physician was alerted by a nurse that the patient was less responsive and unable to eat.

• The following day, the decedent underwent a peritoneal lavage and antibiotic therapy.

• She died 4 days later.

First certificate

• Cause of death: “cardiopulmonary failure due to end stage renal

disease due to diabetes” with “bacterial peritonitis” as a contributing factor”

• Manner of death:Natural

Certificate review

• Cause of death: “Chemical peritonitis following infusion of liquid

feeding supplement through peritoneal dialysis catheter placed for treatment of renal failure due

to essential hypertension.”

• Manner of death:Accident

ELECTIVE TERMINATION OF PREGNANCY WITH UTERINEINJURY

• 33 year old woman– Elective termination of a 5 months gestation at a

physician’s office. – Received ketamine, meperidine, and diazepam with a

lidocaine paracervical block.– A suction dilation and curettage was performed– Patient had an hemorrhage and went into shock and

then cardiac arrest.

• The physician ignored the patient for more than an hour after the procedure.

• Autopsy: approximately 1000 mL of blood and clot in the abdominal cavity and pelvis.

• There was a 3 laceration of the right cervix involving the vagina and uterus.

• Cause of death: “Perforation of uterus with hemoperitoneum

during dilatation and curettage for termination of pregnancy”

• Manner of death:Therapeutic complication.

• Cause of death: “Perforation of uterus with hemoperitoneum

during dilatation and curettage for termination of pregnancy”

• Manner of death:Therapeutic complication.

DIS

CUSS

ION

DISCUSSION

“The classification of the manner of death by the medical examiner/coroner is not the sole

determinate for the prossecution of a crime”

“…There is a potential problem when legal concepts are used, rather than medical notions, to classify a manner

of death…”

• Death certificate:– Legal document for certain legal

administrative purposes

• However…

– The manner of death certification• Nosologic classification schema • Medical opinnion • Not an assessment of legal responsibility.

• What factors should be considered?

– Conscious disregard for the patient’s safety is the standard that is used for criminal liability.

– Not an error in medical judgment or a mistake

– A pattern of recklessness also may be considered.

• No physician is immune to a mistake or a bad outcome in patient care.

• Mistakes of judgment should not be liable for criminal prosecution.

• A physician will not be criminally liable for a good-faith error of judgment or an Inadvertent mistake.

• Neglect:– Failure to feed or give appropriate access

to medical care and treatment.

• Patient-Physician relationship:– Physicians have a moral, ethical, and legal

duty to the well-being of their patients.

– If there is a gross, deliberate, deviation from the standard of care, the physician has violated that relationship.

• Willful neglect: – Failure to provide:

• Timely• Consistent• Safe • Adequate • Appropriate

“Services, treatment, and/or care to apatient or resident of a residential health

care facility”

• Typical malpractice or medical negligence deaths do not reach the level of a homicide certification of death.

• Depending upon the circumstances these may be certified as natural, therapeutic complication, or accident.

• As in the nonmedical world, accidents do happen

• Forensic pathologists are in the unique position of having medical knowledge and an understanding of the medicolegal system’s role in the criminal justice system.

• Medical examiners, as well as the public, can report known or suspected abuses.

• A physician who shows a gross and wanton

disregard for the well-being of his patient should be investigated.

• Medicolegal and investigations systems = safeguard the public health

Why not certify these deaths as accidents instead of homicides and

allow the legal system to judge criminality?

• The scope is based on medical expertise

• The forensic pathologist is uniqueley qualified to evaluate these deaths

THANKS A LOT…

TOLÚ 2010 !!!

T= -6 WEEKS