The medical malpractice in Milan-Italy. A retrospective survey on 14 years of judicial autopsies

• Judicial autopsy plays a crucial role in the investigation on lethal cases of suspected medical malpractice and in nearly 70% of such cases, we find the cause of death right from the autopsy. In the majority of cases, the autopsy itself reveals the absence of medical malpractice or the absence of a real causal connection between the suspected malpractice and the patient death.
• Histology appears to be the most important laboratory investigations after autopsy, being mandatory in cases where necroscopy is not resolutive. Post mortem radiological investigations represent useful instruments to detect and provide detailed autopsy evidence; despite so, conventional autopsy is still mandatory.
• In the present study, the most involved branch in suspected lethal medical malpractice is surgery, with abdominal surgery, orthopedics, neurosurgery and gynecology as the main contributors. Non surgical gynecology, followed by internal medicine and paediatrics resulted the most involved medical branches.
• In 70% of our cases the death occurred in a hospital setting. The modal value for the hospitalization length was 1 day. Non-hospital suspected medical malpractice typically dealt with misdiagnosed myocardial infarctions and aortic ruptures.
• More than 60% of cases of nursing malpractice comes from depressed inpatients committing suicide or from inpatients fallen from their beds and died during the following immobilization period.

The medical malpractice is a rising and central topic for the forensic pathologist and forensic autopsies are a mandatory step in the judicial evaluation of the suspected medical malpractice. Reliable national and international registers about the medical malpractice are still missing and nowadays the necroscopic archives are therefore one of the best sources of data about such a complex phenomenon. We analyzed the archive of the Institute of Forensic Medicine of the Milan University from 1996 to 2009 and selected 317 lethal cases of suspected medical malpractice. The mean age of our cases was 60 ± 18 years for males and 58 ± 19 years for the females. In 70% of such cases the patient death occurred in a hospital setting. The first 24 h of hospitalization turned out to be the hottest period for deaths followed by malpractice claims. The surgical branches were obviously the most involved, with abdominal surgery, orthopedics, neurosurgery and gynecology as the main contributors. Just 12% of the total amount of cases came from all the internistic branches put together. Non-hospital malpractice was typically caused by misdiagnosed myocardial infarctions and aortic ruptures. A full forensic report was present in 71 cases (all belonging to the 2007–2009 period): in 69% of cases the judicial autopsy revealed as a sufficient tool for diagnosing the cause of death; medical malpractice was confirmed in only 17% of the whole cases and a causal link between the ascertained malpractice and the patient death was recognized in only 12.7% cases.