Korean J Leg Med.  2024 May;48(2):41-46. 10.7580/kjlm.2024.48.2.41.

Fatal Nitrites Poisoning in the Medical Setting Filed as Alleged Medical Negligence or Malpractice and the Role of Death Investigation: A Case Report

• Park S
• Lee YM
• Kim DY

• KMID: 2556166
• DOI: http://doi.org/10.7580/kjlm.2024.48.2.41

Abstract

This study presents a case of a patient who experienced sudden death due to fatal nitrite poisoning in the medical setting. It also highlights the pivotal role of postmortem examination in enhancing quality assurance in clinical medicine, as well as in providing resolutions for medicolegal disputes to all pertinent stakeholders, regarding the patient’s death. The patient was found dead during admission after orthopedic surgery. The death certificate was issued by the clinician attributing the cause of death to respiratory failure due to pulmonary embolism. This medical certification of death instigated medicolegal disputes, resulting in allegations of medical negligence or malpractice. Subsequently, a death investigation was initiated, and a postmortem examination confirmed nitrite poisoning as the cause of death. This medical evidence obtained from the autopsy could provide clarity in resolving medicolegal disputes surrounding the patient’s unexpected death in a medical setting. Moreover, a comprehensive review of all information obtained through a death investigation could offer valuable insights even for clinicians, as well as for patient’s family and other stakeholders. This includes guidance on certifying the cause of death based on varying levels of medical evidence and implementing preventive measures to enhance patient safety and mitigate the occurrence of unexpected death in the medical setting.

Keyword

Autopsy; Nitrites; Poisoning; Suicide prevention; Death certificates