Diagnosis and treatment:
On February 21, 2019, Wu Mou was admitted to the Obstetrics and Gynecology Department of the East Street Branch of the Municipal Hospital for delivery due to 39 weeks + 5 days of pregnancy, and gave birth to a baby girl at 0:55 the next day, and the baby girl had mild asphyxia after birth, and was sent to the Pediatric Department of the Headquarters of the Municipal Hospital for rescue, and was sent to the Pediatric Neonatal Care Unit of the Headquarters of the Municipal People's Hospital for treatment at about 01:30 on the same day. After childbirth, Wu had contractions and weakness, vaginal bleeding, and in the time of 1:00 a.m. to 2:00 a.m. on February 22, 2019, the amount of bleeding reached 1400ml, because the day was the Lantern Festival, the receiving doctor sent the baby to rescue, and there was no other doctor on duty, so no diagnostic and treatment measures were taken for Wu, until 2:10, glucose infusion treatment was given, and the infusion was only 1500ml. At 3:30, the doctor told the family that "the mother has intermittent bleeding symptoms are being processed, let the family continue to wait", when the family asked to visit the patient, the doctor said: "The delivery room can not be visited, the patient's condition is OK, we are observing treatment." At about 4:40, the doctor signed with the family and informed: "The maternal contraction is not good, it has been bleeding, and the uterus must be removed to stop the bleeding." The doctor informed: "The patient cannot be transferred to the hospital, only in this hospital for surgery, and the mother is not in a good condition and cannot be transferred." At that time, the operating room of the East Street Branch was being renovated and could not be used, and the East Street Branch could only use the gynecological examination room as the operating room for surgery. Around 5:20 a.m., the hospital once again asked the family to sign and inform: "The anesthesiologist has arrived, and the operation requires anesthesia and requires the family to sign the operation." Around 5:45 minutes to start preparing for surgery, during the operation situation is extremely bad, instruments and surgical instruments have been sent to the operating room, the same day 6:00 surgery, 7:40 after the end of the operation, but Wu has not come out of the gynecological examination room, 10:30 died. Cause of death, postpartum outburst, hemorrhagic shock.
Hospital Fault Analysis:
(1) Anesthesiologists practice beyond the scope:
1.1 The practicing physician certificate of anesthesiologist Wang Jinwen, the practice category is clinical, the scope of practice is surgical, and there is no anesthesiology major.
1.2 The practicing physician certificate of anesthesiologist Zhao Yongzhong, the practice category is clinical, and the scope of practice is surgical specialty
(2) The hospital falsifies and tampers with medical records
2.1 The course of the disease is inconsistent, and the recorded diagnosis and nursing records, notices, anesthesia records and other medical records are inconsistent;
2.2 The signature of the anesthesia notice is not signed by the anesthesiologist himself;
2.3 The record and signature of the anesthesia record sheet is not written and signed by the anesthesiologist;
2.4 The contents and signatures of the TCM directives are not written and signed by the anesthesiologist.
(3) The time and facts of medical record writing and blood transfusion do not match,
3.1 The TCM instruction sheet records that 5:40 on February 22 is still in the operation, but the operating room dressing, instruments and article inventory record sheet records are recorded at 5:40 on February 22;
3.2 Wu's death time was 10:44 on February 22, but the transfusion time recorded in the blood transfusion record was February 23.
Appraisal Opinion of the Appraisal Body:
(1) JC1, JC2, JC3, JC4, JC5, JC6 JC8 are not written by Wang Jinwen, and JC7 cannot be judged;
(2) JC9, JC10, JC11, JC12, JC13, JC14 are written by Zhao Yongzhong, and JC15, JC16, JC17, JC18, JC19, and JC20 cannot be judged.
(3) It was found that the words "Group 3" in the first line of JC21 and "Hanging Mouth" in the eleventh line were written by Wang Jinwen, and the words JC21 (other handwriting), JC22, JC23, and JC26 were not written by Wang Jinwen and Zhao Yongzhong.
First Instance Judgment:
The court of first instance adopted all of Wang Xiangdong's representative opinions, and this court held that the focus of the dispute in this case was: whether the defendant municipal hospital was at fault in the process of diagnosis and treatment of Wu, whether its diagnosis and treatment behavior had a causal relationship with Wu's death, whether it should bear the liability for compensation and the proportion of compensation, in this case, the plaintiff claimed that the defendant falsified and tampered with the medical records as the reason, the presumption that there was a fault in the diagnosis and treatment behavior, and bear the liability for compensation, according to the first paragraph of article 8 of the Basic Specifications for the Writing of Medical Records: The medical records should be written in accordance with the prescribed contents, And signed by the corresponding medical staff, "and Article 22, paragraph 3, item 13: Anesthesia preoperative interview record refers to the record of the risk assessment of the patient's proposed anesthesia before the anesthesia is implemented, and the anesthesia preoperative visit is set up on a separate page, and can also be recorded in the course of the disease, including name, gender, age, department, case number, patient general situation, brief medical history, anesthesia-related auxiliary examination results, proposed surgical methods, proposed anesthesia methods, anesthesia indications and issues to be noted in anesthesia, Preoperative anesthesia doctor's order, the anesthesiologist signed and filled in the date, "item 14" anesthesia record refers to the anesthesiologist wrote in the anesthesia implementation of the anesthesia process and treatment measures records. The anesthesia record shall be written on a separate page, including the patient's general situation, preoperative special circumstances, pre-anesthesia medication, preoperative diagnosis, intraoperative diagnosis, surgical method and date, anesthesia method, anesthesia induction and the start and end time of various operations, the name, method and dosage of medication during anesthesia, special or unexpected situations and treatment during anesthesia, the start and end time of surgery, the signature of anesthesiologist, etc. "Because according to the inpatient medical records provided by the defendant, the anesthesiologists in the city people's hospital anesthesia conversation records show that the anesthesiologists are Zhao Yongzhong and Wang Jinwen, However, according to the judicial appraisal opinion issued by the Gansu Zhongke Forensic Evidence Technical Appraisal Center, it was determined that the signature of "Wang Jinwen" at the anesthesiologist in the anesthesia record sheet was not signed by himself, and the content of the anesthesia summary was neither written by Zhao Yongzhong nor written by Wang Jinwen, and the signature of the chinese physician in the TCM order was not Zhao Yongzhong, Wang Jinwen was written, only 3 pages 10-20 were written by Wang Jinwen, and the name and usage of the drug in the 4th page of the TCM instruction sheet were written by Wang Jinwen, "So there is a violation of the " The illegal acts of the "Basic Specifications for the Writing of Medical Records" on the specific provisions made by the subject of the writing and signature of the medical records, At the same time, the medical records recorded by the hospital found that the following problems existed in the inpatient medical records of Wu provided by the defendant: 1. The interim medical order recorded that the delivery time was 2:01 on February 22, 2019, and the delivery time recorded in the course record and obstetric delivery record recorded that the delivery time was 0:55 minutes on February 22, 2019; 2. The start time of subtotal resection of the uterus recorded in the surgical record and the first postoperative course record was 6:00 on February 22, 2019, and the end time was 7:30, but the operation start time recorded in the TCM instructions was 22 February 5 : 10 minutes, and the time of signing by Wu's family in the surgical consent form and the pre-anesthesia conversation record were 5:25 and 5:20 on February 22, respectively; 3. The surgical Chinese medicine instruction sheet recorded that 5:40 on February 22 was still in the operation, but the operating room dressings, instruments, The time record of the inventory record of the goods is 5:40 on February 22, 20194.Wu's death time is 10:4 on February 22, 2019, but the transfusion time recorded in the blood transfusion record is February 23, the above problems make the course record obviously violate the logical coherence, and the defendant fails to make a reasonable explanation for the above contradictions and errors, resulting in the five plaintiffs having reasonable doubts about the medical records and diagnosis and treatment behavior, and thus refusing to conduct a medical damage appraisal, which is also one of the reasons why the medical damage appraisal in this case cannot be carried out, in summary, because the medical records provided by the defendant Wu have problems such as physician signature, logical inconsistencies and other issues According to Article 58 of the Tort Liability Law of the People's Republic of China, "the medical structure is presumed to be at fault in any of the following circumstances:
(1) Violating laws, administrative regulations, rules, and other provisions related to diagnosis and treatment norms:
(2) Concealing or refusing to provide medical record materials related to disputes;
(3) Falsifying, altering, or destroying medical record materials. ", therefore, it should be presumed that the municipal hospital is at fault, according to the principle of inversion of evidence, that is, the defendant municipal hospital proves that it is not at fault, According to the obstetric delivery records in the inpatient medical records of the defendant's municipal hospital, the obstetric delivery records show that: 1. The delivery time of the deceased Wu was not at 0:55 on February 22, 2019, and the bleeding volume in the 2 hours after the birth was not 1730ml, while the medical system showed that the fetus had a large amount of vaginal bleeding within 24 hours of delivery, and the bleeding volume exceeded 500ml, which showed that the defendant's observation of Wu's condition was not careful enough but the defendant did not produce evidence to confirm that effective and active rescue measures were not taken, 2. Combined with the blood routine test report and rescue record, it was shown 3; 56 points of hemagglutination return: thrombin time ratio: can not be converted, but when the 6 city 47 points of the defendant city hospital approved the blood transfusion for Wu, indicating that the defendant underestimated the situation that occurred after Wu's childbirth, there was an inactive treatment; 3 According to the report of the city hospital's discussion record of the death record and the course of the disease, it also showed that the above behavior of the report city hospital had a certain causal relationship with Wu's death, but after Wu's death, his family refused autopsy, resulting in the failure to find out the cause of death, and thus should also bear the corresponding legal consequences. Based on the above analysis, according to Article 54 of the Tort Liability Law of the People's Republic of China, "if a patient suffers damage in the course of diagnosis and treatment activities, and the medical institution and its medical staff are at fault, the medical institution shall bear the liability for compensation." According to the provisions of this court, the court determined that the defendant municipal hospital was liable for 70% of the plaintiff's various injuries.
4) The court of second instance rejected the lawsuit and upheld the original judgment: The court of second instance fully adopted the opinion of the lawyer representing the lawyer; this court held that Article 23 of the Law of the People's Republic of China on Practicing Physicians states that "physicians who implement medical, preventive and health care measures and sign relevant medical certification documents must personally diagnose and investigate, and fill in medical documents in a timely manner in accordance with regulations, and must not conceal, forge or destroy medical documents and related materials." Physicians must not issue medical certification documents that are unrelated to their scope of practice or are inconsistent with the type of practice. Article 8 of the Basic Specifications for the Writing of Medical Records also stipulates that medical records should be signed by the corresponding medical staff, but in this case 'after identification. The medical record of hemp anhydride, the list of Chinese medicine instructions in the doctor Zhao Yongzhong, Wang Jinwen's name is not signed by himself, and some of the content in the anesthesia summary is not written by Zhao Yongzhong' Wang Jinwen, so. It cannot be proved that Zhao Yongzhong and Wang Jinwen personally participated in the diagnosis and treatment of Wu throughout the process. Item 7 of the second paragraph of Article 22 of the Basic Specification for The Writing of Medical Records stipulates: 'The record of surgical inventory refers to the record of the itinerant nurse's blood, instruments, dressings, etc. used in the operation of the surgical patient, which shall be completed immediately after the operation. The surgical inventory record refers to the itinerant nurse's record of the blood instruments, dressings, etc. used in the operation of the surgical patient, which should be completed in time after the end of the operation. The time recorded in the operating room dressing, instruments and items list record in this case was 5:40 on February 22, 2019, but the TCM instructions recorded that Wu was still in surgery at this time, and the records of the operation time of the two materials were inconsistent. In addition, Wu died at 10:44 on February 22, 2019, but the temporary medical order in the medical record shows that he was still being treated from 12:02 on February 22 to 01:11 on February 23, and the time recorded in the blood transfusion/blood product safety record sheet was also February 23, 2019. In the lawsuit, the appellant argued that the above problems arose because of the urgency of the rescue of the patient, and the Court held that even if the situation was urgent, the medical staff should provide medical services in accordance with the regulations and truthfully write medical records, and the appellant's statement was not a reasonable explanation. Article 57 of the Tort Liability Law of the People's Republic of China stipulates: 'If medical personnel fail to fulfill their medical obligations corresponding to the medical level at that time in their diagnosis and treatment activities, causing damage to patients, the medical institution shall bear the liability for compensation." The above-mentioned problems in the medical records in this case made it impossible to determine that the appellant had fulfilled his due medical obligations to Wu, so the appellant should bear the liability for compensation for the consequences of Wu's death.
In summary, the appellant's grounds of appeal of the Municipal People's Hospital should not be rejected'• The first-instance judgment found that the facts were clear and the judgment was appropriate, and the original judgment should be upheld. According to the first paragraph of article 177 of the Civil Procedure Law of the People's Republic of China, the judgment is as follows: the appeal is rejected and the original judgment is upheld.
Case Considerations:
This case has great reference value for patients who defend their rights in medical disputes. Medical litigation and its complexity require our lawyers to have a strong accumulation of medical knowledge, but we need to think repeatedly when handling cases and find the best litigation strategy to help patients protect their rights. Through the analysis of medical records, I believe that the hospital falsified and tampered with medical records, the anesthesiologist practiced beyond the scope, the time node was inconsistent, the note identification should be carried out, and article 58 of the Tort Liability Law was applied, and it was presumed that the hospital was at fault, and that the hospital's fault had a direct causal relationship with Wu's death, and should bear the main responsibility; in this case, the patient did not do an autopsy and needed to bear the adverse consequences of not being able to find out the cause of death, but in this case, after the deduction and screening of various strategies in the case, I think the best strategy for the patient in this case is to abandon the identification of medical damage liability, mainly focusing time and energy, from letting the court determine that the hospital has a major negligence in falsifying medical records, and then determining that the hospital bears 70% of the liability ratio; I believe that if we choose to do medical damage liability appraisal for medical records through a forensic appraisal agency, to a large extent, the proportion of fault liability of the hospital is not high, so that the patient's rights protection fails.
Remarks: This case is handled by lawyer Wang Xiangdong, a member of the experts, and cannot be reproduced and modified without authorization, otherwise legal responsibility will be pursued.