A hospital has been ordered to pay about 160 million won ($123,800) after a patient who underwent an endoscopy died from an adverse reaction to propofol. The reason: the hospital did nothing wrong with administering propofol or providing emergency care but was negligent in monitoring the patient.

The Seoul Northern District Court ordered a medical professional to pay 167.34 million won in damages in a lawsuit filed against the hospital by the family of a deceased patient.

The patient died in June 2021 after undergoing a gastrointestinal endoscopy at the hospital’s comprehensive checkup center in Nowon-gu, Seoul. The autopsy concluded that the direct cause of death was a sedation side effect of propofol, a general anesthetic. The total dose of propofol estimated during the trial was about 300 mg.

The bereaved family claimed that the patient died due to the negligence of the hospital’s medical workers, including the doctor who performed the endoscopy.

First, the family said, the doctor was not an anesthesiologist but allegedly injected an excessive amount of propofol in a short time and did not adequately monitor the patient’s condition until after he had finished his examination, despite the patient’s showing signs of respiratory depression.

The family also pointed out that medical workers failed to provide first aid. “They delayed CPR even though the patient showed signs of respiratory depression and did not perform endotracheal intubation until the paramedics arrived at the hospital,” they said.

‘Patient became cyanotic due to desaturation, but monitoring was poor’

The court recognized that the doctor was negligent, failing to monitor the progress of the endoscopy and leading to the patient's death.

“During an endoscopy after propofol administration, the patient’s oxygen saturation dropped to 88-90 percent, but the physician did not take any action except briefly discontinuing propofol administration,” it said.

The court also pointed out that medical workers did not continuously monitor the patient’s condition during the examination and recovery process, although he showed symptoms of hypoxia. At the time, the doctor’s medical records contained only blood pressure, pulse, and respiratory rate before and after the endoscopy but nothing about the examination process or subsequent recovery.

The hospital claimed it had assigned exclusive nursing staff to the recovery room and monitored the patient’s condition, but the court did not accept the allegation.

“It was reasonably foreseeable that once the oxygen saturation dropped, it would highly likely drop again and respiratory depression occur, so they had to conduct a more vigilant monitoring,” it said. “However, it appears that no monitoring occurred for about 47 minutes after the patient was moved to the recovery room until the medical staff identified cyanosis.”

The National Forensic Service, which conducted the autopsy, submitted an opinion that “it is difficult to conclude that the deceased patient was under optimal care for his best safety.”

A medical record reviewer also stated, "It is difficult to conclude that vital sign measurements in the recovery room were sufficiently monitored if they were only taken once and not repeated at least every five minutes.”

No clinical negligence in administering propofol or first aid

However, the court did not recognize any negligence in the administration of propofol or subsequent emergency care, as alleged by the bereft family.

“Propofol is highly individualized, and the dose and rate of administration should be based on the patient’s characteristics and response to the procedure rather than the recommended dose. The doctor’s method of administering propofol is common practice in clinical medicine and cannot be considered excessive in dose or rate,” it said.

The court also found nothing wrong with the doctor, a non-anesthesiologist pain physician, administering it. As the relevant society has provided guidelines for administering propofol by non-anesthesiologists and recommended that “simple procedures, including diagnostic endoscopy, can be performed by medical staff participating in the procedure to monitor sedation, the physician’s acts were not considered incompatible with the standard of care practiced in clinical medicine,” it said.

Nor did the court accept the claim that the medical workers at the hospital provided inadequate emergency care by delaying CPR or failing to intubate.

When the patient was moved to the recovery room at 9:59 a.m. and did not wake up by 10:50, the physician determined that he was in cardiac arrest at 10:55 and administered epinephrine while performing CPR. The 911 call was made at 11:02, and the paramedics arrived about 17 minutes later, at 11:19.

“Clinically, there is no requirement that endotracheal intubation be performed immediately upon the onset of respiratory depression from propofol administration or that Dr. C performs it promptly. In addition, the physician took emergency measures, including initiating CPR and administering epinephrine while ambush bagging,” the court said. “These steps were not inadequate or bad enough to worsen the condition.”

Therefore, the court ruled that the doctor and other medical workers were only liable for damages for negligence in observation. The court also considered that the deceased patient suffered from high blood pressure and that the hospital’s medical staff tried to prevent medical errors.

Accordingly, the hospital ruled that the doctor and the hospital’s operator were jointly liable for compensating 167.34 million won.