AUTOPSY REVEALS THE CAUSE OF LITIGATION – A NEGLIGENCE-BASED STUDY

Background : Today the number of cases of allegations of negligence is increasing and already it has become a great problem, especially for surgeons, anesthetists, obstetricians, and gynecologists. Objectives : The present study is an attempt to discover through autopsy what are the basic drawbacks in the service of healthcare which leads to allegations against medical practitioners. Methodology : The study included 72 cases with an allegation of medical negligence cases reported for expert opinion to the tertiary care center. Results : The present study revealed that the surgical, allied & related cases (48) faced more allegations than the medicinal, allied & related cases (21). Autopsies were conducted further in 24 cases out of the 32 surgical deaths which were more as compared to medicinal deaths undergone autopsies (10 out of 16). Conclusions : Of the 72 cases studied, there is a preponderance of allegations related to negligence in the surgery performed (23.61%), which was followed by allegations related to failure to diagnose/ wrong treatment (20.83%).


INTRODUCTION
India is witnessing an alarming surge of 5 to 6 million injuries annually caused by medical errors and unfavorable occurrences.The escalating trend of medical negligence cases and the declining standard of healthcare in India necessitate urgent attention.The repercussions of medical malpractice are distressing, both emotionally and financially, for healthcare providers, patients, and their families.This predicament is not exclusive to India but a widespread problem worldwide.
Medical negligence is defined as the absence of reasonable care and skill or willful negligence of a medical practitioner in the treatment of a patient, which causes bodily injury or death of the patient.Autopsies have been an important tool in the field of medicine for centuries, providing crucial insights into the functioning of the human body and helping to advance medical knowledge.In recent years, autopsies have also become an important means of identifying medical negligence.
Medical negligence occurs when a healthcare professional fails to provide adequate care, resulting in harm or injury to a patient.Identifying medical negligence can be challenging, as it often requires a thorough investigation of the patient's medical history, treatment, and any contributing factors.However, autopsies can provide a wealth of information about a patient's condition and the medical care they received, making them a valuable tool in identifying cases of medical negligence.
In this article, we will explore the role of autopsies in identifying medical negligence.We will discuss some of the common causes of medical negligence, how autopsies can reveal the cause of death, and how this information can be used to correlate it with clinical diagnosis.Overall, this article will provide valuable insights into the complex world of medical negligence and the vital role that autopsies can play in identifying and preventing it.
The objective of this study is to record the results of autopsies and potential instances of malpractice in situations referred to as allegations of negligence at a tertiary care centre located in central Maharashtra, India.
MATERIALS AND METHODS This study was conducted in the Department of Forensic Medicine and Toxicology at a tertiary care center in central Maharashtra, India, as part of a dissertation for partial fulfillment of the postgraduate curriculum.For this study, a total of 72 cases were included, all of which involved allegations of medical negligence reported over a period of three years, specifically between 2013 and 2016.The data used for this research were obtained from various sources, including clinical records, inquest reports, post-mortem examination reports, histopathology reports, and the patients' medical histories, as collected from their attendants.Additionally, expert opinions were sought and incorporated into the study's analysis.Prior to data collection, necessary permissions were obtained from the Dean and Medical Superintendent, with a commitment to uphold the confidentiality of each case evaluated by the expert committee.
The following factors were considered for the study: 1. Age and sex of the patient 2. Specialty against which the allegation of negligence is made (medical or surgical specialty).3. Damage due to treatment by the specialty against which negligence was alleged.4. In alleged cases of negligence on which an autopsy was performed, consistency of the cause of death on autopsy compared to the final clinical diagnosis.5. Distribution of cases according to various accusations related to damages that had occurred due to negligence.

OBSERVATIONS:
The present study was conducted in a tertiary care center from 2013 to 2016, in which available data from a total of 72 cases were studied.The observations of the study are as follows: 1. Age and gender distribution: Out of the 72 cases studied, 42 (58.33%)consisted of females, while 30 (41.66%) consisted of males (Table no 41.66%58.33% 100 Overall, the number of cases related to surgical aspects with allied branches and superspecialties (66.6%) outnumbered the cases related to medical aspects with allied branches and super-specialties (29.16%).This finding, which indicates a surgical preponderance over medical cases, aligns with the observations of Mukesh Yadav 1 and S Janani 4 .
. Additionally, in most cases (31 out of the total 72 cases), the age group of females between 21 and 40 years had the highest number of allegations against surgical and allied procedures, likely due to this age range being associated with the peak fertility period for women.

Distribution of cases based on the damage that occurred:
The present study revealed that the number of survived cases related to medicinal treatments (5) was lower compared to the number of survived cases related to surgical procedures (16) (Table no.2).Autopsies were conducted in 24 out of the 32 surgical deaths, which was a higher percentage compared to the autopsies performed on medicinal deaths (10 out of 16).The cases that survived had damages related to physical injury, mental agony, and unnecessary economic losses for the treatment, leading to allegations of negligence.In the current study, out of the 72 cases, a medicolegal autopsy was performed in 37 cases following an allegation of negligence.Among these cases, 24 were associated with the surgical and allied fields, while 10 were related to the medicinal and allied aspects.

DISCUSSION
Any death occurring after a mishap during treatment or surgery, and if a medicolegal case is filed, the autopsy serves as an eye-opener in many cases, particularly when the cause of death during treatment has not been mentioned or when there is a dilemma over the diagnosis.The final cause of death on autopsy holds significant importance in determining whether charges of negligence should be brought against the treating doctor.Furthermore, autopsies often reveal previously undiagnosed facts that may partially or completely differ from the initial diagnosis.
In this study, a total of 26 cases were related to the field of obstetrics and gynecology, with 19 cases specifically reporting allegations against gynecologists.Out of these 26 cases, only 6 were related to the gynecology aspect, whereas the majority, comprising 20 cases, were related to obstetrics (including antenatal care, vaginal delivery, cesarean section, and postnatal care).Among the cases, 8 had undergone cesarean section (LSCS), 6 had a trial of labor, and 2 had forceps delivery.Consequently, the allegations primarily revolved around cesarean sections, as this surgical procedure was considered safer in certain absolute conditions where a normal vaginal delivery would have posed risks.Naturally, it becomes distressing for the families when they encounter unexpected outcomes following a cesarean section, considering the procedure's associated costliness, thereby increasing the possibility of litigation against obstetric surgeons.
Although the rupture of the uterus following a cesarean section (LSCS) is not an uncommon complication, recent studies on the causes of uterine rupture have shown an increasing likelihood of allegations of medical negligence in cases of post-LSCS deaths 5 .
Out of the 24 cases in the surgical field, only 5 cases had a cause of death on autopsy that was consistent with the clinical diagnosis stated in the hospital papers.In 7 cases of surgical deaths and 2 cases of medicinal deaths, the clinical diagnosis either differed from the cause of death on autopsy or was not stated.The partial correlation or difference between the postmortem cause of death and the clinical diagnosis indicates an error in judgment by the doctor, which could have been one of the causes of an allegation of medical negligence.A study by Edulla NK et al 6 revealed that evidence of negligence was more prevalent in surgical cases compared to medical cases based on autopsy examinations.Kuppast et al 7 observed that 45% of the allegations were attributed to incorrect treatment or procedures, with medical disciplines accounting for 75% of all allegations and surgical disciplines accounting for 25%.In our study, there was a case of a road traffic accident (RTA) with complaints of vomiting, where the treatment protocol was followed for managing the head injury.However, an autopsy revealed blunt trauma to the abdomen with hemoperitoneum and a fracture of the pelvic bone, which had gone undiagnosed.
Out of the 10 medicinal and allied deaths, 3 cases had the cause of death on autopsy consistent with the clinical diagnosis, and in 5 cases, the cause of death on autopsy partially correlated with the clinical diagnosis.In 2 cases of medicinal deaths, the clinical diagnosis was either completely different from the cause of death on autopsy or not stated.According to Fanggang et al 8 , in a study of 190 malpractice claims, 94 cases were accurately diagnosed through clinical examination and confirmed by autopsy.However, 68 cases were diagnosed incorrectly, and 28 cases were not clearly determined.In one case, the clinical diagnosis was pneumonitis, but on autopsy, situs invertus was discovered, with all visceral organs located on the opposite side, including dextrocardia.This clearly indicated that the clinical examination was not conducted meticulously, and the x-ray findings were not observed with precision, leading to a rare clinical case going unnoticed.Hence, it is important to emphasize the significance of accurate diagnosis and sound judgment in following a specific treatment protocol to avoid the liability of medical negligence.The failure of physicians, anesthesiologists, and radiologists to diagnose the mentioned cases could potentially result in charges of negligence against them.The partial correlation or difference between the postmortem cause of death and the clinical diagnosis indicates an error in judgment by the doctor, which might be one of the causes of an allegation of medical negligence.
In one surgical case of subacute intestinal obstruction due to faecolith, the patient underwent surgical exploration to remove the faecolith.However, upon the patient's death, the autopsy revealed that a 20 cm long faecolith was still present within the transverse colon.The doctor should have followed the practice of ensuring the success of the surgery by using radiological investigations when necessary and should not have hesitated to re-explore if any part of the procedure was left incomplete.Agarwal et al 10 reported a case of maternal death during the treatment of a 36-week gravida.In response to allegations of death due to negligence, a medico-legal autopsy was conducted.The results of the autopsy revealed a ruptured ectopic pregnancy as the cause of death.Autopsy examination reports have shed light on numerous cases of maternal deaths, often revealing the cause of postpartum hemorrhage.This highlights the significance of postmortem examinations in the context of maternal deaths and their role in assessing the potential negligence on the part of the doctor.
Evaluating the number of patients who might have had a higher chance of survival if their clinical diagnosis had not been mistaken is a daunting task, even when considering autopsy evidence regarding the cause of death.

CONCLUSION
In cases where death is alleged to be a result of negligence, a medicolegal autopsy becomes essential to provide expert opinions on the matter.Conducting such autopsies requires utmost care from forensic experts, as they present the most challenging examinations, even considering potential reporting issues 6 .Therefore, an autopsy should be conducted meticulously, involving a multidisciplinary examination with the involvement of specialists who have a specific interest in cases involving alleged deaths due to negligence.While autopsy findings can be used to support a doctor's actions in cases of alleged negligence, it is important to acknowledge that autopsy information is also utilized to initiate legal proceedings 11 .However, it should be noted that autopsies hold value for doctors as they provide precise causes of death, including instances of negligence, accidents, therapeutic misadventures, or medical errors.When rare but significant events are identified during autopsies, it is crucial to thoroughly analyze and evaluate the findings, identify risk factors, and implement preventive measures to prevent similar incidents in the future 6 .
Effective communication with patients and their relatives during the initial consultation is crucial in preventing unwarranted accusations.It is important for doctors to allocate adequate time for this purpose.Negligence allegations can have a significant emotional impact on healthcare providers, patients, and the wider community.Therefore, medical professionals may opt to obtain professional indemnity insurance, which provides comprehensive legal protection and financial compensation in the event of any professional liabilities 7 .

RECOMMENDATIONS
.1).Nearly half of the cases belonged to the age group 21-30 (38.90%), with the majority being females (22 out of 28 in this age group).The elderly age group, above 70, had the lowest number of cases compared to the other age groups.The observation of female dominance over males aligns with the studies conducted by Niturkar G 3 and S. Janani 4 .Similarly, the dominance of the age group 21-30 years coincides with the study by S. Janani 4 .

Table ( 2
): The distribution of cases based on the damage that occurred.

Table ( 3
): Cause of death on autopsy in correlation with clinical diagnosis wherein death occurred.
1.It is important for doctors to stay informed about new developments in their field and stay up to date with evolving medical knowledge.This enables them to provide the best possible care to their patients.2. Accurate and complete medical records play a crucial role in delivering quality care.They help doctors avoid errors or oversights and ensure continuity of treatment.3. When faced with complex medical cases or unfamiliar conditions, doctors should seek consultation or referral to specialists who have expertise in managing such cases.This collaborative approach ensures optimal care for the patient.4. Doctors should only perform procedures and treatments within their scope of competence.If faced with procedures or treatments beyond their expertise, they should seek additional training or consult with specialists to prioritize patient safety.