Medicolegal Causation Investigation of Bacterial Endocarditis Associated with an Oral Surgery Practice Using the INFERENCE Approach.

Putri Dianita Ika Meilia,Maurice P Zeegers,Herkutanto Herkutanto,Michael D Freeman

doi:10.3390/ijerph18147530

Abstract

Investigating causation is a primary goal in forensic/legal medicine, aiming to establish the connection between an unlawful/negligent act and an adverse outcome. In malpractice litigation involving a healthcare-associated infection due to a failure of infection prevention and control practices, the medicolegal causal analysis needs to quantify the individual causal probabilities to meet the evidentiary requirements of the court. In this paper, we present the investigation of the most probable cause of bacterial endocarditis in a patient who underwent an invasive procedure at a dental/oral surgical practice where an outbreak of bacterial endocarditis had already been identified by the state Department of Health. We assessed the probability that the patient’s endocarditis was part of the outbreak versus that it was an unrelated sporadic infection using the INFERENCE (Integration of Forensic Epidemiology and the Rigorous Evaluation of Causation Elements) approach to medicolegal causation analysis. This paper describes the step-by-step application of the INFERENCE approach to demonstrate its utility in quantifying the probability of causation. The use of INFERENCE provides the court with an evidence-based, transparent, and reliable guide to determine liability, causation, and damages.

Highlights

Published: 15 July 2021Causation is broadly defined as the cause-and-effect relationship between an action and an outcome
The causal question was formulated based on the competing causal theories/legal hypotheses of the opposing parties
This causal question was in the form of comparison or ratio of probabilities based on counterfactual reasoning, as follows: “What was the risk of bacterial endocarditis (BE) to Mrs D as a patient of Dr X during the timeframe of interest compared to her risk of BE during the same timeframe had she not been a patient of Dr X?” The complexity of the causal question and, in particular, the need for a quantified answer ruled out the use of intuition alone as a sufficient approach

Summary

Introduction

Causation is broadly defined as the cause-and-effect relationship between an action and an outcome. The investigation of causation is a primary goal in forensic/legal medicine, a multifaceted discipline that is a hybrid of medicine, law, and public health [1,2]. Medicolegal analysis of causation is necessary in legal actions involving injury, disease, and death to establish the nexus between an unlawful or negligent act and a subsequent adverse outcome. The complexity of causal evaluations ranges widely, with many assessments of simple cases requiring only the application of scientific common sense and professional intuition [3]. A more in-depth causal investigation is warranted. A representative example is a medical negligence (i.e., malpractice) action involving a disease outbreak that has allegedly resulted from a faulty medical procedure or practice. There are many facets to such an investigation, and a systematic approach that maximizes the transparency of methods is ideal

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