Medical malpractice as reflected by the forensic evaluation of 4450 autopsies

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Abstract

A multicentre retrospective analysis of 4450 autopsies carried out due to suspicion of medical malpractice in 17 German institutes of forensic medicine from 1990 to 2000 was performed for the German Federal Ministry of Health. During the time period analysed an increase of cases could be mentioned. The main results of the study are: in the cooperating institutes the total number of autopsies due to suspected medical malpractice ranged from 1.4 to 20%. In more than 40% of the cases preliminary proceedings were started because the manner of death was certified as non-natural or not clarified. Hospital doctors were more affected by medical malpractice claims than doctors in private practice. However, the number of confirmed cases of medical malpractice was higher for doctors in private practice than for hospital doctors. Although surgery is still at the top of the disciplines involved in medical malpractice claims the number of confirmed surgical cases was below the average. Mistakes in care were confirmed to be above the average. Medico-legal autopsies are still a very sufficient method to evaluate cases of medical malpractice: 2863 cases could already be clarified by autopsy. Up to now there is no systematic registration of medical malpractice charges in Germany. A systematic registration should be initiated to build up and/or improve error reporting systems and, thus, to improve patient safety. Compared to other sources of medical malpractice claims (arbitration committees of the medical chambers, reference material of health and insurance companies, files of civil courts) the data of the present multicentre study are in so far unique as only lethal cases were evaluated and a complete autopsy report was available as basis of an expert opinion in alleged medical malpractice cases.

Introduction

Clear data on the epidemiology of medical malpractice are missing, at least for Germany [12], [21], [22]. Furthermore data on the frequency of medical malpractice claims – both in penal and in civil law – are not available (Table 1).

For Germany it is estimated, that only 1500–2000 cases per year are investigated by the public prosecutor, these are mainly cases where death is thought to be due to medical malpractice and cause and manner of death have to be cleared by a medico-legal autopsy. In penal law it is estimated that one investigation by the public prosecutor is performed on 60,000 inhabitants, one lawsuit filed on 90,000 inhabitants. Only eight cases per year are brought to a penal court with four convictions and four stays of proceedings [47].

For civil law data on the frequency of medical malpractice claims are also not available, estimations speak of about 15,000 claims per year [22], [33].

Every doctor is obliged to have a liability insurance, data from the liability insurance companies are, however, not available as well [27], [64], [71], [74], [75], [76]. One insurance company with 108,000 insured doctors reported about 4500 complaints a year with a settlement of cases in 30%, 10% go to a civil court and in 4% medical malpractice is confirmed at court.

In Germany most claims of medical malpractice are dealt with at the arbitration committees of the medical councils (Table 2) [2], [16], [17], [46], [53]. More than 30 years ago the medical councils founded these arbitration committees to make medical malpractice claims possible without applying to the court. More than 10,000 cases per year are dealt with at the arbitration committees and in 30% patient claims are confirmed. The data of the arbitration committees of the medical councils are meanwhile published once a year on a national basis (MERS: Medical Error Reporting System) [2].

However, from epidemiological and health care research important data on the frequency of adverse events (AE), preventable adverse events (PAE) and negligent adverse events (NAE) are available [6], [25], [56], [57], [58], [59], [66], [67]. According to a systematic review of the German Alliance of Patient Safety AE can be expected in 5–10%, PAE in 2–4%, NAE in about 1% and lethal outcome in about 0.1% of hospitalized patients. Thus, on a yearly basis of 17.5 million hospitalized patients in Germany 880,000–1,750,000 AE, 700,000 PAE, 175,000 NAE and 17,500 deaths could be expected. This would mean that in Germany nearly as many people would die due to consequences of medical diagnoses or therapies than due to colon cancer (20,200), breast cancer (18,000), pneumonia (17,800) and traffic accidents (7700). Similar data have already been published for the UK (Fig. 1).

However, the data from epidemiological research are not compatible with figures from civil and penal law and they were questioned after their publication [31], [32], [35], [37], [47], [58], [59]. Nevertheless they are in accordance with other international studies: e.g. the Institute of Medicine stated that up to 98,000 patients die of preventable medical errors in American hospitals each year [25]. Among 850,000 individuals dying in US hospitals per year a major diagnosis remains clinically undetected in at least 8.4% (71,400 deaths). Furthermore 34,850 patients would have survived until discharge had misdiagnoses not occurred [62], [63]. One of the Institute's of Medicine recommendations called therefore for a mandatory reporting system for deaths and serious injuries [25]. Medico-legal death investigation systems are one component of this approach. These figures on the frequency of AE, NAE, PAE and deaths – this has to be kept in mind – were calculated from epidemiological- and health care research studies.

Data on malpractice cases are furthermore available from the files of the institutes of forensic medicine [1], [5], [9], [10], [15], [20], [28], [31], [32], [33], [36], [37], [38], [39], [40], [41], [44], [50], [52], [54], [60]. As the arbitration committees are mainly dealing with living patients, lethal cases are found within the material of the arbitration committees only in 2.7% of all cases.

The best available data source on lethal cases is in the files of the institutes of forensic medicine. This subgroup is of special importance since death is the most severe outcome of medical malpractice and the reproach to have caused the death of a patient by medical malpractice is the most severe malpractice claim.

Section snippets

Materials and methods

In Germany not only reliable data on medical malpractice charges in penal law are missing but also data on lethal cases. A few studies of data from the files of the institutes of forensic medicine were carried out in the past [1], [9], [10], [28], [29], [38], [39], [40], [43], [44]. To obtain a broader data basis we carried out a standardized retrospective analysis on medical malpractice claims in lethal cases for the German Federal Ministry of Health [51], [52]. This multicentre analysis was

Frequency of autopsies due to medical malpractice claims

The autopsy rate in the participating institutes of forensic medicine is differing widely. E.g. in Munich in the study period more than 21,000 autopsies were carried out, in Cologne only 1274. While in Munich 669 autopsies were due to medical malpractice claims, in Cologne nearly one quarter of all autopsies were due to malpractice claims. The percentage of autopsies due to malpractice claims on all autopsies is varying widely between 1.9 and 20%. High rates of autopsies due to medical

Discussion

Medical malpractice claims in penal law have increased over the years from 300 to 600 cases in the cooperating institutes. However, there is not an increase or boom of medical malpractice claims like in civil law [40], [72]. For Germany about 1000–1500 autopsies per year due to medical malpractice claims can be expected today [32], [47].

An interesting information is that the majority of cases comes to the attention of the public prosecution by certifying the manner of death as unnatural or

Conclusions

Autopsies are the essential basis for determining the cause of death, medical negligence and causality of negligence for cause of death. Without autopsy lethal cases cannot be judged in an appropriate way. Autopsies are, however, not only the essential basis for expert evidence in a practical case but also for preventing similar cases. They provide data on events that are significant – serious injuries – and that are much more comprehensive than provided to most reporting systems. Autopsy

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    Supported by grants from the Federal Ministry of Health.

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