[Unexpected fatalities of patients in medical treatment]

Our results are based on 190 autopsy records of unexpectedly deceased patients in connection with medical treatment between 1984 and 1993. 161 times autopsy has been ordered by the local Public Health Office to establish cause of death. In 5 of these cases indications of medical maltreatment were found and the cases had been brought to trial. Inspite of suspected problems with medical treatment the treating doctors certified natural death in 8 of these cases and autopsies were carried out by general pathologists. Secundarily these cases were brought to court and corpses were reexamined by forensic pathologists. 29 times autopsy has been ordered by court from the beginning. 102 patients (53.7%) died during medical treatment ("mors in tabula"), while 88 patients (46.3%) died within days or weeks after treatment. 135 fatal incidents occurred in surgery, 13 cases during diagnostic procedures or puncturing veins, 5 cases after drug administration, 5 cases during attempts at resuscitation, and 8 fatal cases during other special treatment. 11 times no medical treatment has been started (omission). Legal consequences of 42 cases done by court were: no accusation in 48%, only accusation and cessation in 26%, condemnation in 21% and acquittal in 5%.