Med Sci Law. 2013 Sep 3. [Epub ahead of print]
Lethal pulmonary thromboembolism: An autopsy-based study on a rare but legally relevant event.
Source
Laboratory of Medical Malpractice and Health Liability, Institute of Forensic Medicine, Milan University, Italy.
Abstract
Context: Pulmonary thromboembolism (PTE) is the severe end stage of many different diseases producing prolonged patient immobilization or a hypercoagulative state. Lethal PTE is also one of the most frequent topics for suspected medical malpractice, especially dealing with patients originally affected by non-critical illnesses and suddenly killed by a non-prevented embolic event. The crucial forensic question about a lethal PTE is the following one: was this lethal PTE an unpreventable complication or was it a consequence of a real medical malpractice?Materials and methods: The authors analyzed the 1999-2009 autoptic archive of the Institute of Forensic Medicine of the Milan University and selected all the cases having a PTE as the cause of death. For every selected case, the authors also collected all the available demographic and clinical data. Statistical analysis was performed using SPSS V.16.00.Results: In the period 1999-2009, 129 (1.25%) cases out of a whole amount of 10,288 autopsies were diagnosed as having suffered lethal PTE. The male to female ratio was 1:2 (34.1% versus 65.9%). The mean age at death was 67 ± 18 years. In 41% of cases the exitus occurred away from the hospital and in the absence of any medical support, in 36.5% during the territorial paramedical support or during the very first evaluation in the emergency department and in the remaining 22.5% during a period of hospitalization. In 33.4% of the selected cases, a typical preliminary event was positively identified: a pure major trauma (18.6%), a trauma followed by a major surgery (7%), a major non post-traumatic surgery (7%) and a non-surgical delivery. Symptoms suggesting PTE were detected in 46 cases (35.7%). Nine cases underwent a judicial autopsy in the same original hypothesis of a medical malpractice for wrong prophylaxis in acutely bed-restricted patients.Conclusions: Post-surgical PTE cannot be automatically labeled as a consequence of medical malpractice. The combination of right prophylaxis, careful diagnostic monitoring of the high-risk patient and right therapy surely reduces the occurrence of lethal PTE, but it does not completely erase such an insidious pathology. In the hypothesis of a causative medical malpractice, only the careful analysis by an experienced forensic pathologist can make a reliable distinction between an unpreventable complication and a real medical malpractice.
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