An "unwitting" intracranial surgery:

The family of the patient who died after surgery claimed millions, and the hospital was sentenced to be 40% responsible in the first instance

■ On the evening of August 2021, 8, Wen Yunzhi, who was 21 years old at the time, suddenly had a headache accompanied by consciousness disorders and was sent to Hebei PetroChina Central Hospital. Admitted to the intensive care unit with "subarachnoid hemorrhage" in the emergency department. After two days of treatment, Wen Yunzhi's consciousness gradually improved, and he was able to breathe spontaneously out of the ventilator. Four days later, when Wei Zhenxia came to the hospital early to visit, she found that her husband had been pushed out of the ICU, and the doctor told her that she was going to have a cerebral angiogram for Wen Yunzhi. It was not until Wen Yunzhi was pushed out of the operating room in the afternoon of the same day that his family knew that the hospital had performed an intracranial aneurysm embolization operation for him. "We didn't know that the hospital was going to operate on him (Wen Yunzhi) that day, and none of our family members had signed an informed consent form for the operation." Wei Zhenxia recalled that when she saw Wen Yunzhi being pushed out of the operating room, she found that he was unconscious, "I don't feel like I can do it anymore." ”

■ On September 2021, 9, Wen Yunzhi passed away. Wei Zhenxia believes that when her husband's condition was improving, the hospital performed an intracranial aneurysm embolization operation on her husband without the consent of the family and without adequate examination, and the operation failed, resulting in her husband's death. After that, Wei Zhenxia and his daughter sued Hebei PetroChina Central Hospital in court, demanding that it take responsibility for Wen Yunzhi's death and compensate for it. On September 4, 2023, the verdict of the first instance of the case was announced. The court held that based on the conclusion of the judicial appraisal and the "failure to sign the patient during the operation" in the reply letter, the hospital was ordered to bear 9% of the liability. Both the original defendant and the defendant did not recognize the first-instance judgment and appealed. At present, the second instance has not yet been heard.

The man was hospitalized with a sudden headache

Vital signs were relatively stable after two days of treatment

"It was the eve of the 15th day of the seventh lunar month, and when he (Wen Yunzhi) returned home, he said that his head was uncomfortable." Wei Zhenxia recalled that at that time, she asked her husband Wen Yunzhi if he could drive to the hospital, and after receiving a negative answer, she called the emergency number.

According to the medical records, Wen Yunzhi was admitted to the hospital at 2021:8 on August 22, 0, and was diagnosed with subarachnoid hemorrhage and intraventricular hemorrhage after cranial CT examination. The hospital performed endotracheal intubation and left and right ventricular puncture and drainage on Wen Yunzhi overnight. By 30:2021 on August 8, 23, when the doctor made a ward round, the medical records showed that Wen Yunzhi "suspended sedation this morning and opened his eyes when called", "breathing and circulation were relatively stable", and "weaned as appropriate".

"I accompanied him in when I did the CT scan on the 8rd [of August], and he did whatever he was told to do, and I did see that he was out of danger." Wei Zhenxia said. She told reporters that at that time, she sent the relevant information of her husband's condition to "classmates working in Beijing University Hospital", and the classmates said that since Wen Yunzhi was out of danger, it was recommended to observe and undergo imaging and other examinations to confirm the cause. But at the time, the doctor told her, Wei said, "The imaging machine in the hospital is broken, so you have to wait." ”

On August 2021, 8, Wei Zhenxia signed the "Notice of Neurointerventional Treatment" (hereinafter referred to as the "Notice") for her husband. According to the "medical description and treatment recommendations" in the notice, the patient was clinically diagnosed with subarachnoid hemorrhage, intracranial aneurysm? The treatment recommendation is to undergo cerebral angiography and aneurysm interventional embolization under general anesthesia if necessary, so as to prevent rebleeding and improve the quality of life. In addition to interventional treatment, there is also craniotomy clipping. The notice also mentions that the operation needs to be carried out according to the patient's condition, but there are certain risks and there may be surgical complications and other unforeseen accidents, so we solemnly explain to the patient or the entrusted agent the accidents and complications that may occur during or after the operation, including but not limited to 23 unexpected situations such as "encountering other unpredictable circumstances during the operation (including serious abnormalities of important functional organs, etc.), resulting in life-threatening circumstances".

The medical record on August 2021, 8 showed that "the patient's vital signs are relatively stable and he is weaned", and two doctors from the Department of Neurosurgery reviewed the patient and "recommended further cerebral angiography to confirm whether there is an intracranial aneurysm and improve preoperative preparation". Wei Zhenxia said that because the hospital could not perform imaging, she went to the hospital that day and proposed, "Since your machine is broken, don't make imaging, and then we will transfer to the hospital", and the other party replied at that time, "The machine should be fine soon, don't worry."

Sudden imaging

Surgery followed by "poor prognosis for the patient and the possibility of death at any time"

It's August 2021, 8. Wei Zhenxia recalled that at around 25 o'clock that morning, when she went to visit again, she saw Wen Yunzhi being pushed out of the ward, "I thought he was going for a follow-up CT examination." Wei Zhenxia said that at that time she was told that the imaging machine had been repaired, and Wen Yunzhi was pushed to do cerebral angiography. Wei Zhenxia said that at that time, she considered that she was going to have a check-up, so she signed the informed consent form for cerebral angiography. This was recorded in the medical record: at 8:2021 on August 8, 25, the attending doctor and the deputy chief physician of the Department of Neurosurgery analyzed after the ward round, "the patient's life constitution is relatively stable, and cerebral angiography was performed today to confirm whether there is an intracranial aneurysm".

Wei Zhenxia recalled that Wen Yunzhi was pushed into the operating room for imaging at around 9 a.m. that day, and the doctor came out at around 11 a.m. to tell her that Wen Yunzhi had moyamoya disease and intracranial aneurysm.

According to public information, moyamoya disease is a cerebrovascular disease of unknown etiology, characterized by chronic progressive stenosis or occlusion of the ends of bilateral internal carotid arteries and the beginning of the anterior cerebral artery and middle cerebral artery, and secondary to the formation of abnormal vascular networks at the base of the skull. Because this abnormal vascular network at the base of the skull resembles "smoke" on the cerebral angiography image, it is called "moyamoya disease".

Wei Zhenxia said that because she studied medicine and consulted relevant experts, she had made it clear to the hospital that if Wen Yunzhi was found to have a congenital vascular malformation, "don't touch it", and moyamoya disease is a congenital vascular malformation. Wei Zhenxia said that it was the neurosurgeon who informed her of the results of Wen Yunzhi's cerebral angiography, "I said at the time that he (Wen Yunzhi) was born with this kind of virtue and did not do it." I said it twice in a row and didn't do it. ”

Wei Zhenxia said that the doctor said he knew at the time, and then returned to the operating room of the cerebral angiography. It was around 11 o'clock in the afternoon, and the family members were sitting at the door of the operating room waiting to push Wen Yunzhi out, and it was not until about 5 p.m. that Wen Yunzhi was pushed out of the operating room. "Seeing that he didn't have any consciousness or reaction, there was blood in the drainage bag, and he was on a ventilator, he felt like he couldn't do it anymore." Recalling the scene when she saw her husband being pushed out of the operating room, Wei Zhenxia cried.

The medical record at 2021:8 on August 25, 16 showed that the patient was in a coma after surgery, with a GCS score of "01T", bilateral unequal pupils, and no light response. According to medical professionals, a GCS score of less than 2 means deep coma or brain death.

The medical record of the next day of surgery reads, "The patient underwent cerebral angiography yesterday, diagnosed: moyamoya disease, intracranial aneurysm, and transcatheter intracranial aneurysm embolization under general anesthesia to consider intraoperative bleeding. ”

Since then, Wen Yunzhi has relied on high-dose drugs and ventilators in the hospital to maintain himself. Wei Zhenxia said that although his family was expecting a miracle, Wen Yunzhi passed away on September 2021, 9.

The court of first instance found that

"The patient was informed that the patient did not sign during the operation" and the hospital was sentenced to bear 40% of the compensation liability

Shortly after Wen Yunzhi's death, in September 2021, Wei Zhenxia and his daughter sued Hebei PetroChina Central Hospital in court, demanding that the hospital take responsibility for Wen Yunzhi's death and compensate more than 9.113 million yuan for medical expenses, funeral expenses, death compensation, and spiritual comfort.

Wei Zhenxia and his daughter believe that the defendant violated medical and health laws and regulations and clinical operation norms, did not pay enough attention to the patient's condition, and failed to closely follow and observe the patient's condition; Surgery for the patient despite strong opposition from the family and high risk of surgery and the operation failed, resulting in the patient's eventual death.

The defendant, Hebei PetroChina Central Hospital, argued that there was no causal relationship between the death of the patient Wen Yunzhi and him, and cited the high mortality and disability rates of patients with ruptured intracranial aneurysm (cerebral hemorrhage), and the rapid development and change of the disease. The interventional operation took 5.5 hours, which was not very smooth, and it was clear that blood vessel rupture and bleeding occurred during the operation, which was a clear cause of blood pressure fluctuations and other reasons, so as to prove that the intraoperative blood pressure control was in line with the diagnosis and treatment routine and there was no fault.

The reporter learned that after the case entered the judicial procedure, the court entrusted a third-party judicial appraisal agency to evaluate whether there was medical fault in the diagnosis and treatment of Wen Yunzhi in Hebei PetroChina Central Hospital. Thereafter, the appraisal institution issues an appraisal opinion by reviewing the medical records submitted for examination, holding a doctor-patient opinion statement meeting, etc.

On August 2021, 8, Wen Yunzhi performed a cerebral angiography examination, and moyamoya disease, intracranial aneurysm, and multiple cerebral vascular occlusions were found during the operation; In this case, it is more difficult and unpredictable to perform intracranial aneurysm embolization, and the hospital should inform the patient's family in detail about this situation and obtain the consent of the family before corresponding treatment. There is a relevant notification in the existing medical record materials, but there is no signature confirmation from the patient's family. In this appraisal, the patient's point of view was stated, and the Chinese medicine doctor informed him, but the patient's family said that they did not agree to the embolization operation. This objective factual issue is beyond the scope of this appraisal, and the court is requested to clarify the trial in conjunction with relevant evidence.

The appraisal agency believes that through the review of the medical records submitted for examination, the anesthesia record reflects that the blood pressure of the identified person has fluctuated greatly during the operation, which can be an important cause of intraoperative rebleeding, so the hospital is at fault in the intraoperative blood pressure control, and there is a certain causal relationship between the repeated rebleeding after the appraised person's intraoperative embolization and the gradual aggravation of the postoperative condition and finally death. In the end, the appraisal opinion held that Hebei PetroChina Central Hospital had medical negligence in Wen Yunzhi's diagnosis and treatment, and there was a certain causal relationship between his medical negligence and Wen Yunzhi's death.

On September 2023, 9, the Guangyang District People's Court of Langfang City made a first-instance judgment in this case, ruling that Hebei PetroChina Central Hospital should bear 22% of the compensation liability for Wen Yunzhi's death, and compensate for medical expenses, death compensation, funeral expenses, judicial appraisal fees, spiritual solace and other losses totaling more than 40,42 yuan. In the first-instance judgment, it was specifically pointed out that the defendant should bear 4% of the liability for compensation, which was determined based on the appraisal conclusion of the above-mentioned appraisal agency and the "failure to sign the patient during the operation" in the reply letter.

After receiving the judgment, both the original defendant were dissatisfied with the judgment and appealed. Wei Zhenxia and his daughter believe that the hospital should bear full responsibility for Wen Yunzhi's death. Hebei PetroChina Central Hospital held that Wei Zhenxia had signed the "Notice of Neurointerventional Treatment" two days before the operation, and that the hospital had informed the family of the patient's condition and the risks of the operation, and that the operation would be carried out after the patient's consent and signature, so the court of first instance determined that the hospital assumed 40% of the responsibility based on the "failure to inform the patient's signature during the operation" in the appraisal conclusion "obviously has no factual and legal basis".

Wei Zhenxia told reporters that a few days ago, she had received a notice from the court of second instance that the case would be heard in the Langfang Intermediate People's Court in the near future.


Procedures and special examinations should be clearly notified

Regarding this case, Fu Jian, director of Henan Zejin Law Firm, said in an interview that China's Civil Code, Physician Law, Basic Medical Care and Health Promotion Law, etc., all have clear provisions on the obligation to inform in diagnosis and treatment activities and the patient's right to informed consent.

For example, Article 1219 of the Civil Code of the People's Republic of China stipulates that medical personnel shall explain the patient's condition and medical measures in the course of diagnosis and treatment. Where surgery, special examinations, or special treatment is necessary, medical personnel shall promptly explain to patients specific circumstances such as medical risks and alternative medical treatment options, and obtain their explicit consent; Where it is not possible or appropriate to explain it to the patient, it shall be explained to the patient's close relatives and their explicit consent shall be obtained. Where medical personnel fail to fulfill the obligations in the preceding paragraph and cause harm to patients, the medical establishments shall bear responsibility for compensation.

In light of this case, a lawyer in Beijing with a medical background believes that the hospital should be clearly informed of what kind of treatment it does, and "it is impossible to inform all of them in one notice." It explained that there are many types of neurointerventional treatment, but the law stipulates that if surgery, special examination, or special treatment is required, the medical risks need to be specified and the patient's explicit consent must be obtained. Even if it is the same type and not the same name, different hospitals should be notified separately. ”

Ma Tairong, deputy chief physician of emergency medicine of Chongqing West District Hospital, said after learning about the medical records of this case that according to the diagnosis and treatment standards such as the "Clinical Diagnosis and Treatment Guidelines for Neurosurgery", "Clinical Pathway of Moyamoya Disease" (2017 Edition), "Chinese Expert Consensus on the Treatment of Moyamoya Disease" and "Chinese Expert Consensus on the Diagnosis and Treatment of Moyamoya Disease and Moyamoya Syndrome", during the cerebral angiography of this case, moyamoya disease was "accidentally" found, and there was an aneurysm on the moyamoya blood vessels.

According to Ma Tairong, the treatment of moyamoya disease is mainly "revascularization" to increase blood supply to the ischemic area. Perimoyamoya disease-type aneurysms with no signs of bleeding usually do not require treatment and may be spontaneously occluded after "revascularization"; Most common aneurysms can be embolized to avoid intracerebral hemorrhage. "Because of the important differences in the principles of treatment of unruptured moyamoya disease aneurysms and other common aneurysms, new conditions have been identified during surgery and should be evaluated more carefully." Ma Tairong pointed out that due to the particularity of moyamoya disease, the content of preoperative informed consent is exceeded, and special notification should be made and explicit consent should be obtained.

Now, Wei Zhenxia is anxiously waiting for the second trial to begin. She said that after her husband underwent surgery, he owed hundreds of thousands of yuan in medical expenses, and the hospital urged her to return it.

Chengdu Business Daily-Red Star News reporter Zhang Yanliang reported in Langfang, Hebei