MALPRACTICE AUTOPSIES

SUMMARY According to autopsy studies, failure to diagnose and misdiagnosis are common in critically ill patients. When medical malpractice is suspected in adults dying after a surgical procedure, some of the attending physician's diagnoses will probably be proven wrong. Autopsy is underused, for a variety of reasons. Medical malpractice counsel should routinely encourage complete autopsy.

CRITICALLY ILL CLIENTS

According to autopsy studies, failure to diagnose and misdiagnosis are common in critically ill patients.

Medical ICU

A recent study 1 of 41 autopsies from a single medical Intensive Care Unit (ICU) found unexpected causes of death in one third. Selection for autopsy was by the consent of the families, all of whom were routinely asked.

In almost all cases detailed post-mortem examination provided new diagnoses that would have been clinically relevant, and that would have changed management in one quarter.

Surgical ICU

Similar figures are found in studies of surgical ICU patients, and the striking difference is that infections are the dominant source of error 2.

Deaths occurring more than 7 days after blunt trauma are overwhelmingly caused by infection 3.

Nosocomial (hospital-acquired) infection is more than twice as common in surgical ICU as on general surgical wards 4. Commonly missed are peritonitis, lung abscess, endocarditis, and bronchopneumonia 5, 6.

Practice Point

In surgical patients, infections are the commonest source of diagnostic error

Whether failure to observe standard preventative procedures such as routine hand-washing is likely to prove a successful cause of action has been addressed previously.

Pediatric ICU

Although rates of unexpected findings at childhood autopsy are about half those in adults, infections are again dominant, but undiagnosed malformations, particularly of the heart, also figure significantly 7.

Suspected Malpractice

When medical malpractice is suspected in adults dying after a surgical procedure, some of the attending physician's diagnoses will probably be proven wrong.

Major diagnostic discrepancy rates of well under 10% have been reported when the autopsy rate approaches 100% 8.

By contrast, for postoperative deaths in which medical malpractice is suspected, autopsy found erroneous diagnosis in the majority.

15 adult autopsies requested because of suspicion of medical malpractice 9, revealed new information in 10 and "most of the diagnoses performed by the physician in charge of the patient at the time of death were wrong."

In nearly half the cases, correct diagnoses would have modified treatment and potentially altered outcome.

TYPES OF ERROR

Autopsy is underused, for a variety of reasons.

The generally accepted classification 10 of types of diagnostic error distinguishes between major and minor diagnoses (Dx), and whether or not treatment (Rx) or outcome would have been altered by the correct diagnosis:

Type   Dx Error Rx/Outcome
I   Major Changed
II   Major Unchanged
III   Minor Unchanged
IV   Minor Changed
V   None  

As previously reported, there has been a dramatic fall in autopsy rates during the last three decades. Various causal factors have been proposed:

Practice Point

Reasons for low autopsy rates:
1. Advanced diagnostic methods
2. Accreditation requirements
3. Medical school de-emphasis
4. Malpractice fears
5. Family nonconsent
6. Cost containment

Although physicians commonly believe that more sophisticated tests result in fewer diagnostic errors, the evidence from autopsy studies 10 11 contradicts that view. Indeed, over-reliance on new technologies may contribute directly to major diagnostic error.

Medical schools are still officially encouraged 12 to use the postmortem examination as a teaching tool:

As part of the educational program, it is important that autopsies be performed whenever possible and appropriate. A sufficient number of autopsies representing an adequately diverse spectrum of diseases should be performed to provide an adequate educational experience and to enhance the quality of patient care.

Nevertheless, the focus on different learning methods is reflected in the abolition of minimum autopsy rates for hospital accreditation. Even the most explicit US requirements, those for internal medicine residency training 13,

All deaths must be reviewed, and...autopsies should be performed on at least 15% of deaths..

are low compared with those of a few decades ago.

At the individual level, physicians in a litigious environment are much less likely to encourage grieving relatives to consent to autopsy 14, and thereby risk having their mistakes uncovered.

Detailed postmortem examination is both expensive and, of course, of no personal benefit to the patient.

Family members may recoil from having the body of the loved one further butchered after death.

The deceased's desire to donate organs for transplantation or research may conflict with wishes for a meaningful autopsy.

Treating physicians may be interested only in post-mortem examination of certain tissues - the brain, for instance.

MEDICAL MALPRACTICE ACTIONS

Medical malpractice counsel should routinely encourage complete autopsy.

Diagnostic error does not mean substandard care, mistakes do not equate with negligence.

However, for purposes of a medical malpractice action arising from suspected diagnostic or therapeutic error, complete autopsy is often invaluable. Not only may the evidence for the proposed cause of action be augmented, but corrected or additional diagnoses may add contributory negligence.

Practice Point

Counsel for medical malpractice plaintiffs and their families should vigorously promote FULL autopsy after critical illness

As in clinical examination, the detail with which a given body part is examined post mortem, and the tests applied, are determined in part by the history of the illness. The pathologist all too often receives an incomplete or distorted history and the autopsy provides less than comprehensive answers.

Practice Point

A medicolegal resource physician should, when appropriate submit supplementary history and questions to the pathologist

For medicolegal purposes, the questions that should be asked are materially different from those that immediately concern the treating physicians. Whenever appropriate and possible, the medicolegal resource physician should be asked to submit a supplementary history for consideration by the pathologist.

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