A district court has found an internist in his 70s guilty of professional negligence for injuring a patient during a colonoscopy, causing a controversy in the medical community.

Korea Biomedical Review obtained the recently released judgments of the first and second trials to see the details of the case and the reasons for the sentence.

On Aug. 14, the Incheon District Court upheld the original (first) trial verdict that sentenced the physician, an internal medicine specialist, to six months in prison and two years of probation for professional negligence. The physician claimed no fault and said the punishment was excessive, but the verdict was rejected.

In April 2021, the doctor was indicted for causing a colon perforation during a colonoscopy and failing to take proper measures, resulting in injury to a patient. The patient suffered a colon perforation and peritonitis after the colonoscopy, which required surgery and hospitalization.

On the day of the incident, the patient completed her endoscopy at 9:30 a.m., complained of upper abdominal pain, and underwent an X-ray at 12:20 p.m.

The results of the examination ruled out a possible intestinal perforation, and she was discharged from the hospital at around 3:00 p.m. However, she continued to complain of pain and was transferred to the emergency department of another hospital three days later. The patient underwent a Hartmann operation for colon perforation and peritonitis there and was hospitalized again for localized peritonitis.

At trial, the physician testified that the X-ray showed no free air in the abdominal cavity to indicate a perforation and that he “ordered discharge due to the patient's ambiguous level of pain.” The doctor argued that “even if the duty of care is exercised, perforation may inevitably occur” during colonoscopy and that “all necessary measures were taken at the level of a medical institution at the time.”

The lower court found the doctor guilty of ‘disclaiming the violation of the duty of care although the patient was injured.’

The court disagreed, however.

On Sept. 8 last year, the Bucheon branch of the Incheon District Court, which handled the first trial of the case, found the doctor guilty of professional negligence.

The court found that during the examination, the doctor “attempted to insert the endoscope somewhat forcefully and hit the colon wall, causing a perforation.”

It also noted that the doctor testified in court that “the patient had a history of hysterectomy at an advanced age, which increased the risk of intestinal perforation” and that “at the time of the examination, there was some difficulty in passing (the endoscope) through the colon.”

The court added that the doctor stated in a phone call with the patient shortly after the incident that “there was some speculation that (the scope) might have been strained when it went in.” The doctor explained the patient's condition in the call, stating that “sometimes (the machine) gets bent and unbent, which can result in perforations.”

The doctor also stated that he misinterpreted the X-rays when deciding to discharge the patient from the hospital. At the time, the doctor believed that he did not have free gas in her peritoneum, but a medical evaluation raised doubts.

The Korea Medical Dispute Mediation and Arbitration Agency said, “It is difficult to confirm a definite finding,” but a related association said, “Free gas is suspected.”

The doctor replied, “I saw the yellow fibers, but I thought it was fecal residue stained with food and bile. I did not predict that a perforation of the mesentery caused it.” He said he “lacked experience or knowledge” and “judged it as food” when he saw the video.

“This is the first time I've ever had a perforation like this,” the doctor said. “It was a little different from a normal perforation. I hadn't seen what a mesenteric perforation looks like. I didn't have that experience. I didn't have enough experience or knowledge, so I thought it was food.”

The tribunal concluded that “the doctor himself admitted that he did not recognize the possibility of perforation” even after viewing the video.

Furthermore, the failure to refer the patient to a hospital for a CT scan was also problematic. The doctor argued that he had done all he could at the clinic level, but the court did not accept this argument.

“The patient should have been transferred to a nearby hospital with access to an abdominal and pelvic CT scan to further investigate the possibility of a perforated bowel,” the tribunal said. “The doctor did not do so, making it difficult to say that the doctor did all that was necessary.”

The court noted that the injuries suffered by the patient due to this negligence were “not minor and the damage has not been repaired” and that “The doctor denied breaching his duty of care and was unrepentant and unforgiving to the patient.” However, the court took into account that he had no criminal history.

The appeals court upheld the original verdict because ‘the internal medicine specialist did not fulfill his duty of care’

The physician appealed the verdict, but the outcome remained unchanged.

At the appeals trial held on Aug. 14, the Incheon District Court’s Criminal Division rejected all of the doctor’s appeals and upheld the ruling of the first trial.

As the patient showed “suspicious circumstances,” including constant pain and slow recovery, the doctor should have “paid more attention to the symptoms and not ruled out the possibility of colon perforation.”

“As an internal medicine specialist, the physician was well aware that even if the free gas was not identified on the X-ray, a CT scan could be more accurately diagnosed,” the appeals tribunal noted. “And he should have taken appropriate measures, such as showing the X-ray images to a radiologist or referring the patient to a higher medical center for a CT scan.”

However, the doctor “did not pay much attention” to the patient's complaints and “appears to have discharged him casually.”

The tribunal concluded: “The patient consistently states that the physician told her that she “made too much of a minor pain.’ The doctor admitted that he 'spoke to the patient in a way that suggested she was sensitive.’ As a patient, this comment by the specialist would have left her with no choice but to go home in extreme pain.”

“In the end, it is reasonable to conclude that the doctor failed to exercise the duty of care required of an average internist, resulting in the victim's serious injury, including peritonitis,” the court said.

The sentencing continued, “In light of the sentencing conditions, including his age and circumstances, the motive, means and consequences of the offense, the circumstances after the offense, and his criminal record, the sentence imposed by the trial court does not appear to be too severe and unjustified, taking into account the circumstances that he asserts as grounds for appeal.”

Accordingly, the court dismissed the doctor’s appeal as lacking merit and upheld the original sentence.