doiSerbia

An unperformed autopsy does not exclude the possibility of proving a physician´s error

Anđelić Slađana (Municipal Institution for Emergency Medical Care, Belgrade, Serbia)

Introduction/Objective. Clarifying cases involving suspicious natural death and all forensic problems connected to such cases is possible only with the aid of a timely and adequately performed autopsy. The objective of this paper, however, is to point out the fact that it is possible to prove the existence of a physician’s error, even when an autopsy had not been performed. Case report. The Emergency Medical Service (EMS) team had been dispatched to respond to a call for help by a 53-year-old woman, complaining of chest pain, shortness of breath, and dizziness. The pain was located in the center of her chest and would increase in response to palpation, change of body position, and deep breathing. The physical examination was normal. The EMS physician concluded that it was not necessary to perform electrocardiography (ECG). Forty minutes later, the EMS team was dispatched to see the same patient again, this time for suspected cardiac arrest. Protocol-based cardiopulmonary resuscitation (CPR) for asystole was performed, without success. After 30 minutes, CPR was discontinued and the patient was declared deceased. Although the patient’s relatives did not allow an autopsy to be performed, they did send a claim to the Health Inspector at the Ministry of Health of Serbia, demanding an internal review of the physician’s professional work. It was concluded that the physician should have performed ECG, but that the true cause of death could only have been determined through a timely and adequately performed autopsy. Conclusion. An unperformed autopsy does not exclude the possibility of proving a physician’s error.

Keywords: absence, evidence, autopsy, medical error