Court rejects ₩160 million damage claims for failing to diagnose iliac artery bleeding

A court has rejected a 160 million won ($119,850) lawsuit filed by a bereaved family against a hospital for failing to diagnose an iliac artery bleeding in time, leading to the patient's death.

The iliac artery is located in the retroperitoneum, the back of the abdominal organs. The bleeding in this area is difficult to recognize because it proceeds without apparent signs and symptoms.

On Aug. 13, the Seoul Central District Court dismissed a lawsuit for damages filed by the bereaved family of the patients initialized as A against the hospital initialized as B. The court ruled that the medical staff was not negligent because there were no circumstances to suspect iliac artery bleeding and that it could not believe the angiogram was performed too late.

According to the ruling, the 74-year-old male patient complained of edema and numbness in his lower extremities after receiving intramuscular stimulation (IMS) treatment on Sept. 8 and 9, 2021, at a hospital-and-oriental medical clinic initialized as C. The following day, the director of the C hospital-and-oriental medical clinic wrote a medical referral to a higher-level hospital, and patient A visited the emergency room of the hospital B on the same day.

The higher-level hospital’s medical staff conducted blood tests, and its Neurosurgery Department performed a cerebrovascular CT-MRI examination to check for stroke. As a result, there were no acute lesions. He was then referred to the Orthopedic Department for a lumbar and pelvic X-ray, which showed a disc or stenosis. Most of his vital signs, including blood pressure, temperature, and oxygen saturation, were normal, except for his hemoglobin level, which was 8.8 g/dL, below the normal range of 13-18 g/dL.

The medical staff suspected a herniated disc and discharged him at 12:40 a.m. the following day (Sept. 11) after giving him painkillers.

However, on Sept. 13, 2021, two days after being discharged, the patient visited the emergency room of Hospital B again, complaining of difficulty in mobility and eating. A blood test showed his hemoglobin level was only 4.2-4.3 g/dL. After administering a blood transfusion, the medical staff at the hospital performed an emergency head, neck, chest, and abdominal X-ray and an abdominal CT scan.

The results showed that retroperitoneal hematoma, rhabdomyolysis, and acute kidney injury were suspected, and angiography was performed to determine the need for embolization and continuous renal replacement therapy. However, the patient’s pulse rate dropped rapidly, so CPR and endotracheal intubation were performed first. After his pulse recovered, blood transfusions and inotropes were prescribed, and he was admitted to the nephrology ICU.

Thirty minutes after being admitted to the ICU, his pulse rate dropped again, so the medical team performed CPR, and once he was resuscitated, they attempted to perform angiographic embolization to treat the retroperitoneal hematoma. However, he went into cardiac arrest for a third time, and after CPR, embolization was performed, and hemostasis was confirmed. However, after being transferred to the ICU, he went into cardiac arrest again, and despite CPR and ventilator treatment, he died. It was a day after visiting the hospital’s emergency room. The cause of death was hemodynamic shock due to iliac artery injury and resulting multiple organ failure.

The bereaved family filed a lawsuit for damages, claiming that the hospital’s medical staff breached their duty of explanation and duty of care in diagnosis and treatment, which led to the patient’s death. The amount claimed was 159.61 million won.

They claimed that the hospital was negligent in failing to diagnose iliac artery hemorrhage by not performing an abdominal CT/MRI examination even though he had symptoms of anemia at the time of his first visit and in delaying emergency treatment by not performing an angiogram as an emergency after an abdominal CT examination when a blood test could have diagnosed massive bleeding at the second visit.

However, the court disagreed.

“At the initial visit, the deceased's vital signs were normal, and his consciousness was lucid,” the court said. “His hemoglobin level was 8.8 g/dL, indicating anemia but not to the extent that a blood transfusion was necessarily recommended.”

The court also noted that anemia is not uncommon in older adults with diabetes and that it would have been difficult for the medical staff to suspect massive bleeding because there were no clinical signs of massive bleeding until the time of discharge.

An expert who reviewed the patient’s medical records at the court's request agreed.

“There were no findings to consider retroperitoneal hemorrhage, massive bleeding, or shock as differential diagnoses, and it is not customary to order an abdominal CT scan immediately for a patient who complains of musculoskeletal symptoms,” the expert said. “It is almost impossible to think of ordering a CT scan based on the history of acupuncture at the clinic as a clue that an arterial injury may have occurred at the site of the groin acupuncture, which may have caused retroperitoneal hemorrhage, which may have caused anemia.”

Regarding the claim that the emergency treatment was delayed, the expert said, “It is difficult to find that the medical staff's negligence caused any delay at any stage. It is said that an angiogram should have been performed immediately after confirming the blood test results without an abdominal CT scan. Still, an abdominal CT scan is necessary to locate the source of the bleeding. The approximate location of the bleeding is necessary to perform an angiogram.”

The court said, “It could be considered from hindsight that an angiogram should have been performed immediately for diagnosis and treatment at the same time, once the site had been identified and death had occurred, as the most desirable treatment. However, it was difficult to see that there was any basis for an angiogram to be performed immediately at a time when it was not clear that the bleeding site was the site of IMS treatment.”

“It is difficult to see that there was any negligence in delaying embolization by angiography when there was an obligation to do so in an emergency,” the court said, dismissing the plaintiff's claim for damages and awarding the plaintiff the costs of the case.