*medical homicide and extreme negligence iván darío gonzález Álvarez carolina hernández riveros...
TRANSCRIPT
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*MEDICAL HOMICIDE AND EXTREME NEGLIGENCE
Iván Darío González ÁlvarezCarolina Hernández RiverosAndrea Modera Hernández
February/10 XI Semester
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CONTENTS
Questions ?
Discussion
Results
Case 1 Case 2 Case 3 Case 4 Case 5
Materials and Methods
Introduction
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• 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
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Deaths During Medical Care
Natural Death
Death due to Therapeutic Complication
Accidental Death
NYC Office of chief Medical Examiner and Department of Forensic Medicine
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• 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
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• 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.
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Manslaughter Reckless homicide
Medically Related Deaths
Reckless Endangerment
Deaths Certified as Homicide
Criminally Prosecuted
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• Manslaughter:– Medical caregiver intentionally causes the
death of the patient
• Reckless endangerment– Death is due to treatment by an
unlicensed fraud or quack.
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• 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.
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MAT
ERIA
LS A
ND
MET
HO
DS
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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
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• 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
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RESU
LTS
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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
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• 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.
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• 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.
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“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.
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• 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.
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• 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.
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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
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• 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.
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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.
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• 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.
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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
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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
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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.
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• 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.
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• Cause of death: “Perforation of uterus with hemoperitoneum
during dilatation and curettage for termination of pregnancy”
• Manner of death:Therapeutic complication.
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• Cause of death: “Perforation of uterus with hemoperitoneum
during dilatation and curettage for termination of pregnancy”
• Manner of death:Therapeutic complication.
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DIS
CUSS
ION
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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…”
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• 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.
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• 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.
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• 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.
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• 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.
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• 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”
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• 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.
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• 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.
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• 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
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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
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THANKS A LOT…
TOLÚ 2010 !!!
T= -6 WEEKS