Perspective | A Review of Practical Views on Missed Diagnosis Medical Disputes

The patient has been experiencing left chest and back pain for 10 days without relief. Accompanied by children, they went to the pain department outpatient clinic of a municipal hospital, where the diagnosis was myofascial pain syndrome of the chest and back. The hospital performed a chest spiral CT scan; RSWT once (on the left chest and back) and prescribed medication. The next morning, the son found the patient had difficulty breathing, weakness in hands and feet, coldness, and black lips, and at 8:44 AM, took the patient to the emergency department of a municipal hospital for rescue. After emergency treatment, the patient was transferred to the cardiology department for hospitalization. Later, at the patient's request, the municipal hospital transferred them to a provincial hospital for treatment.
 

After being hospitalized at the provincial hospital for half a month, due to the patient's critical condition and being in shock, the patient's family applied for discharge. The patient was hospitalized for 20 days at the provincial hospital, with discharge diagnoses including: 1. Acute ST-segment elevation extensive anterior and high lateral myocardial infarction; 2. Acute heart failure cardiogenic shock heart function grade IV; 3. Arrhythmia ventricular fibrillation paroxysmal atrial fibrillation complete right bundle branch block left anterior fascicular block; 4. Coronary atherosclerotic heart disease; 5. Pulmonary hypertension (mild); 6. Paroxysmal atrial fibrillation; 5. Complete right bundle branch block; 6. Pulmonary infection; 7. Acute renal failure; 8. Acute liver function damage; 9. Type 2 diabetes; 10. Hypoproteinemia; 11. Post-cholecystectomy. On the evening of March 15, 2021, the patient was sent home and died on March 18. The resident death medical certificate (inference) recorded the cause of death as myocardial infarction. The patient's family believed that the hospital had faults such as missed diagnosis during treatment and sued the municipal hospital in court.

The court commissioned a certain judicial appraisal office in Shanghai to assess whether there was medical fault, causal relationship, and participation degree in the treatment process of the patient by the municipal hospital. On June 10, 2022, the Shanghai judicial appraisal office issued an appraisal opinion, stating:The municipal hospital lacked recognition of the symptomatic attributes of the patient whose main complaint was left chest and back pain, failed to fulfill the duty of high attention, leading to a missed diagnosis in the context of the patient's myocardial infarction gradually worsening for about 10 days, delaying the best diagnostic treatment opportunity, resulting in the patient's death; there is a certain causal relationship between this and the patient's death, with a participation degree of 25% to 40%.
 

If a patient suffers damage during medical activities and the medical institution and its medical staff are at fault, the medical institution shall bear compensation responsibility. The court believes that regarding whether the municipal hospital should bear medical damage tort liability in this case, since medical behavior is a highly specialized, quite complex, and inherently risky activity, determining whether the medical institution has fault in the treatment process and whether that fault has a causal relationship with the patient's current damage relies on specialized analysis and conclusions from appraisal institutions with professional knowledge, experience, and skills.
 

In the above case, the court legally commissioned a certain judicial appraisal office in Shanghai to conduct medical damage appraisal. The appraisal office issued a judicial appraisal opinion, and the qualifications of the appraisal subject were legal, the appraisal process was proper, and the basis for the appraisal conclusion was sufficient, thus having high scientific and impartiality, so this appraisal opinion can be used as evidence to establish the facts of the case. Based on medical records and the appraisal opinion and other evidence,the municipal hospital's first diagnosis department lacked recognition of the symptomatic attributes of the patient whose main complaint was left chest and back pain, failed to fulfill the duty of high attention, leading to a missed diagnosis in the context of the patient's myocardial infarction gradually worsening for about 10 days, delaying the best diagnostic treatment opportunity; resulting in the patient receiving formal treatment only after diagnosis, the efficacy could no longer prevent the complications of myocardial infarction, thus, the municipal hospital had a fault of missed diagnosis in the patient's treatment process, and this fault has a certain causal relationship with the patient's final damage outcome (death about 3 weeks later).

In summary, the court believes that citizens' life and health should be protected by law. If a person infringes on another's life and health due to fault, they should bear tort liability. The municipal hospital's lack of recognition of the symptomatic attributes of the patient's treatment, failure to fulfill the duty of high attention, and missed diagnosis, delaying the best diagnostic treatment opportunity, caused losses to the patient's family. Based on the degree of fault of the municipal hospital, it is determined that the municipal hospital should bear 35% of the compensation responsibility.

In April 2015, the patient visited a university-affiliated hospital due to abdominal discomfort and underwent an abdominal CT scan, which indicated localized wall thickening of the sigmoid colon, bladder stones, bladder wall thickening, and right ureteral hydronephrosis. The hospital recommended the patient to seek treatment at a large comprehensive hospital. Subsequently, the patient was admitted to the Medical University General Hospital in June 2015. Based on the CT findings from the university-affiliated hospital indicating bladder stones, bladder wall thickening, and right ureteral dilation, an ultrasound examination showed bilateral hydronephrosis (more pronounced in the right kidney). On June 17, 2015, the patient underwent cystotomy for stone removal, bladder diversion, and pubic drainage under general anesthesia. During the surgery, adhesions between the peritoneum and intestinal tract were found, and three stones were removed from the bladder, each measuring 2-3 cm. The bladder wall was approximately 1 cm thick, the bladder mucosa was rough, and the ureteral orifices were normal. Three months post-surgery, the patient was diagnosed with an abdominal mass and a bladder-rectal fistula at another hospital. Therefore, on October 6, 2015, the patient was transferred back to the Medical University General Hospital for treatment. A cystoscopy was performed to obtain a biopsy of the mass, and the pathology report indicated cancer, presenting as squamous cell carcinoma, with the possibility of urothelial carcinoma with squamous differentiation not ruled out. After symptomatic treatment, the patient was discharged on December 31, 2015. In January 2016, the patient died of cancer. The patient's family believed that the Medical University General Hospital was at fault for the missed diagnosis and thus sued the hospital.
 

The court commissioned a medical association in a certain city to assess whether the defendant hospital had made any mistakes in the patient's treatment, whether there was a causal relationship between the hospital's actions and the patient's harm, and the degree of fault involved. The medical association issued a "Medical Damage Opinion" stating: (1) The CT report from the university-affiliated hospital indicated that the patient exhibited late-stage tumor characteristics, and bladder cancer could not be ruled out. The hospital failed to further diagnose and differentiate, leading to an inadequate diagnosis. Although the hospital performed a cystoscopy prior to surgery due to the patient's severe hydronephrosis and bladder wall thickening, it focused solely on the morphological examination of the tumor and neglected the histopathological examination. During the cystotomy for stone removal, no further pathological examination was conducted to clarify the diagnosis; the cause of the adhesions found during surgery was not further investigated. The medical actions exhibited faults, which were significant reasons for the missed diagnosis of bladder cancer. (2) The diagnosis of bladder stones was clear, and surgical treatment could be considered. However, the hospital did not consider the possibility of malignant tumors prior to surgery, thus could not provide detailed information about the condition to the family. No pathological examination was conducted during the surgery to clarify the diagnosis. (3) The CT scan from April 28, 2015, at the university-affiliated hospital had already indicated late-stage tumors, and the cystoscopy on October 6 at the Medical University General Hospital confirmed bladder cancer. According to relevant literature, bladder squamous cell carcinoma is clinically rare, accounting for 1%-2% of bladder malignancies, characterized by difficulty in early diagnosis, high malignancy, and poor prognosis.Even if the patient had been diagnosed with bladder cancer at that time, it would have already been in the late stage. Therefore, the patient's death was a natural progression of their malignant tumor. Although the Medical University General Hospital had faults in the missed diagnosis, it cannot be determined that the missed diagnosis had a direct causal relationship with the patient's death. The conclusion is that the patient's death was a natural progression of their malignant tumor, and although the Medical University General Hospital had faults in the missed diagnosis, it cannot be determined that the missed diagnosis had a direct causal relationship with the patient's death.
 

If the patient suffers harm during the diagnosis and treatment process, the medical institution and its medical staff shall bear the compensation responsibility if there is fault on their part. The medical association in a certain city determined in the "Medical Damage Opinion" that the hospital had a missed diagnosis during the treatment process, indicating fault, but it cannot be determined that the missed diagnosis had a direct causal relationship with the patient's death. The court confirmed the conclusions of the "Medical Damage Opinion." The defendant should bear corresponding compensation responsibilities for the economic losses caused by the missed diagnosis during the treatment process.
 

In this case, the fact that the patient was misdiagnosed during their first hospitalization at the defendant Medical University General Hospital led to the patient being hospitalized again at another hospital. Therefore, the related losses incurred during the treatment at the other hospital are a direct consequence of the defendant's missed diagnosis, and the defendant should provide compensation.The patient’s first hospitalization at the defendant was for the treatment of bladder stone removal. According to the conclusions of the "Medical Damage Opinion," this treatment was confirmed to have surgical indications, and three stones were successfully removed from the bladder. The patient's second hospitalization at the defendant was for the clear diagnosis of bladder cancer. Therefore, the related expenses incurred during the patient's two hospitalizations at the defendant are expenses that necessarily arose from their treatment. The defendant is not required to bear compensation responsibility for this.

Mr. Sun, the patient, visited East China Hospital on May 20, 2013. The hospital's preliminary diagnosis indicated: abdominal plain scan + enhanced CT suggested multiple liver cysts, right kidney cystic lesions, and no significant abnormalities in the observed intestinal tract. On May 23, a colonoscopy was performed, and the pathological diagnosis was: (cecum) adenoma; (sigmoid colon) tubular adenoma with low-grade intraepithelial neoplasia; (descending colon) adenoma; (rectum) tubular villous adenoma. Mr. Sun was discharged on May 29, and according to the discharge summary, the main diagnosis upon discharge was: post-polypectomy, with a recommendation for "follow-up in the gastroenterology department" after discharge. On September 3, 2014, Mr. Sun's follow-up colonoscopy pathological diagnosis recorded: high-grade intraepithelial neoplasia in the sigmoid colon.
 

On September 26, 2024, Mr. Sun went to the cancer hospital for consultation. The cancer hospital reviewed Mr. Sun's pathological slides and opined: "tubular villous adenoma, with some glands in the superficial area showing high-grade intraepithelial neoplasia." On October 27, Mr. Sun was admitted to the cancer hospital due to "multiple colon polyps with recurrence and cancer transformation one year after EMR surgery." On October 28, he underwent radical surgery for sigmoid colon cancer under general anesthesia. The postoperative pathology report indicated: (sigmoid colon) mucosal defect at the titanium clip marking site, with surrounding inflammatory cell infiltration and multinucleated giant cell reaction, consistent with changes after EMR surgery, with no residual tumor seen. The lesion was 9 cm from the upper cut and 2 cm from the lower cut, with no nerve or vascular invasion. Mesenteric lymph nodes (0/7) and highest group lymph nodes (0/1) showed no tumor metastasis. He was discharged on October 31, with a discharge diagnosis of sigmoid colon cancer and multiple colon polyps.

Later, Mr. Sun believed that East China Hospital had a missed diagnosis and sued the hospital in court for compensation.

The court entrusted a certain district medical association to conduct a medical damage assessment. On January 22, 2016, the medical association issued a medical damage assessment opinion, and the expert group concluded: 1. The hospital's diagnosis and treatment complied with medical standards. The patient was admitted to the hospital in May 2013 due to elevated CEA and AFP levels, and the hospital conducted comprehensive auxiliary examinations (blood, urine, stool tests, ultrasound, CT scans, endoscopy, etc.). The colonoscopy found multiple polyps in the colon, and after obtaining the patient's informed consent, multiple polyps were removed via EMR and electrocautery, with pathology indicating benign lesions (adenomas). After observation, the patient's condition was stable post-surgery, and they were discharged with the main diagnosis being post-polypectomy, with a recommendation for "gastroenterology follow-up" in the discharge summary. The hospital's treatment of the patient was in accordance with clinical norms. 2. The hospital exercised due diligence in diagnosis and treatment. In September 2014, the patient returned to the hospital for a follow-up colonoscopy, and the pathology indicated high-grade intraepithelial neoplasia in the sigmoid colon. The pathology slides were sent to an external hospital for consultation, which indicated high-grade intraepithelial neoplasia in some superficial glands. When faced with a difficult diagnosis, the hospital promptly sought consultation and handled the situation with caution. 3. The pathology slides from the patient's colonoscopy examinations in May 2013 and September 2014 were reviewed by experts, who agreed with the hospital's pathology department's diagnoses of the two biopsy specimens. 4. In October 2014, the patient underwent a colonoscopy at an external hospital, and the pathology diagnosis indicated surgical indications for radical resection of sigmoid colon cancer. Following medical norms, surgical treatment was performed, and post-operative pathology showed no residual tumor, with negative lymph nodes found in the upper and lower margins, nerves, and vessels. In summary, this case does not constitute medical damage to the patient's person. Assessment opinion: This case does not constitute medical damage to the patient's person.
 

In this case, the focal point of the dispute is the timing of Mr. Sun's polyp cancer transformation and whether the hospital constituted a medical error of missed diagnosis. According to relevant literature, the occurrence of colon cancer is a progressive process, with the average time from the occurrence of adenomatous polyps to cancer transformation being 5-10 years. The risk factors for cancer transformation are related to the size of the adenoma, the morphology of the stalk, the number of adenomas, the growth site, and the patient's age. Mr. Sun's colonoscopy in May 2013 indicated "accompanied by low-grade intraepithelial neoplasia," which indicates that his colon tumor had undergone atypical hyperplasia and was in the progression stage of adenoma transformation, but the specific duration of cancer transformation cannot be clearly determined. Furthermore, colonoscopy pathology testing is considered the gold standard for diagnosing colorectal lesions, but it is not completely accurate. A routine colonoscopy cannot ensure that all colorectal mucosa is observed without blind spots; even with good bowel preparation and sufficient observation time during the colonoscopy, it cannot guarantee that all colon polyps will be detected. Additionally, it is not possible to remove all lesions or potentially diseased tissues for pathological testing during the colonoscopy. The hospital's endoscopic examination operations complied with medical standards and fulfilled the corresponding medical obligations (under the current medical scientific and technological conditions). Therefore, based on the evidence submitted for court verification, the hospital's medical actions do not constitute a medical error of missed diagnosis, and the court ruled to dismiss Mr. Sun's lawsuit.
 

It can be seen that Mr. Sun's final diagnosis result is closely related to the development of his own disease, the limitations of medical science and technology, and other facts. It is neither realistic nor scientific to demand that hospitals make precise judgments on all diseases during the diagnosis and treatment process. Therefore, when determining responsibility, it is necessary to comprehensively consider whether there is a causal relationship between the patient's damage consequences and the hospital's medical behavior, whether the damage consequences were caused by the hospital's fault in medical behavior, and the proportional impact of medical errors on the occurrence of damage consequences.