Prosecution after an outbreak of subacute aluminum intoxication in a hemodialysis center

Abstract

Criminal prosecution of physicians for the death of patients has been extraordinarily rare, but there seems to be a rising trend. This case report describes the medical and judicial implications of criminal prosecution of two doctors at a hemodialysis clinic in the Netherlands Antilles that had to stand trial over the death of 10 dialysis patients. The patients died of subacute aluminum intoxication when aluminum leached from the cement lining of a newly installed water distribution pipe into the water supply of the dialysis center that did not make use of a water treatment system (WTS). Data of the case history of the dialysis patients, the criminal prosecution, preliminary judicial inquiry, the defense arguments and verdicts are reviewed. The prosecutor first decided to dismiss the case, but after an appeal by the families, the Court of Appeal decided to pursue prosecution for gross negligence. It held that the dialysis center should have used a WTS and also held that the dialysis staff reacted insufficiently on extra alarms on the dialysis machines in the two days after the new water distribution pipe was put in use. From June 6, 1998 until January 1999 a preliminary judicial inquiry was performed in The Netherlands and on Curaçao. After a cross-examination of 13 court-appointed experts by the prosecutor and the investigative judge, the prosecutor charged the two physicians of gross negligence manslaughter for not testing the composition of the water after the construction at the water distribution network. A prison sentence with probation of 6 months was demanded. The District Court disagreed on all issues with the prosecutor, but nevertheless held the medical director of Diatel guilty for performing hemodialysis without a WTS. In May 2000, the Court of Appeal held that it was not allowed to rule on the omission to install a WTS because this issue was not included in the charge and overturned the conviction. Medical personnel in charge of potentially dangerous procedures should be prepared for unexpected changes in the quality of their treatment. Because court-appointed experts might have an extraordinary role in the decision making process, guidelines should be prepared to ensure the trustworthiness of their testimony.