FORENSIC MEDICAL AND LEGAL ASPECTS OF THE PROVISION OF MEDICAL CARE IN OBSTETRICS AND GYNECOLOGY

Relevance. Sometimes statistics on medical errors are hushed up, and information about individual incidents becomes known thanks to the media. Objective: to identify the most common obstetric-gynecological profi le defects and their causes by analyzing the data of the State Statistics Service on maternal and infant mortality during pregnancy, childbirth and the postpartum period and compare it with the forensic analysis of obstetric-gynecological profi le medical care. Materials and methods. 625 cases were analyzed according to the State Statistics Service on maternal and infant mortality during pregnancy, childbirth and the postpartum period, court sentences in criminal cases under Articles 139 and 140 of the Criminal Code of Ukraine, according to the Unifi ed State Register of Court Decisions of Ukraine since 2009 in 2019, as well as data from forensic medical examination commissions on “medicinal matters” for 2013-2019 performed by the State Institution “Main Bureau of Forensic Medical Examination of the Ministry of Health of Ukraine”, including cases of previous departmental audits by the commissions of the Health Administration. The data obtained were subjected to statistical processing by standard methods of descriptive statistics. Results. In these 255 examinations, defects in the provision of medical care were found by expert commissions in 186 cases, which amounted to 72.9%. Moreover, of these «defective cases», 62.9% (117 cases) were in a direct causal relationship with an unfavorable outcome; 35.5% (6 cases) in some defi ciencies that did not have a causal relationship with the onset of fetal death. In 3 cases of examinations in gynecology, there were contradictions in the entries in the medical documentation, they did not allow assessing the quality of medical care and the relationship with the consequences. At the pre-hospital stage (in the clinic), defects were allowed in 65.5%, and at the hospital in 72.8%. In the presence of departmental inspections in 23%, there was a complete coincidence of the results of the conclusions of the commissions of the bureau of forensic medical examination and medical examination, and only in cases of signifi cant defects in direct causal connection with the consequences. At the same time, when analyzing 53 court sentences according to the register of court decisions, it turned out that 13 of them related to the obstetric and gynecological profi le, and 12 of them were indictment. In all cases, the source of evidence in cases was exclusively the “Expert Conclusions”. Conclusions. It was found that forensic medical examinations for the provision of obstetric and gynecological medical care occupy a leading place in the overall structure of commission examinations in “medical matters”, in the vast majority of examinations, defects in the provision of medical care were found that were in direct causal connection with an unfavorable outcome.

Relevance. The problem of so-called «medical errors» is relevant even in highly developed countries. For example, in 1999, the US Institute of Medicine published a report entitled «To Err Is Human», which announced that up to 98,000 Americans die each year from medical errors [1]. However, despite the measures taken by Congress (systematic courses and training for medical staff, strengthening control over the work of physicians through the establishment of special commissions), in 2019 medical errors remained just as common. Among the WHO fi ndings: About 10% of hospitalized patients worldwide suffer from nosocomial infections. Medical errors occur in approximately 40% of primary and outpatient patients. Diagnostic and treatment errors are detrimental to millions and cost billions of dollars each year. According to researchers at Johns Hopkins University, 250,000 Americans die each year from medical errors, although no offi cial statistics are available. In Ukraine, offi cial statistics on medical errors are silenced, and information about individual incidents becomes known through the media [4, 5, 6]. It is a clear fact that such errors are common in those areas of medical practice that are associated with emergency surgery, such as obstetrics and gynecology, surgery, anesthesiology [7]. While in Europe and America the issue of correctness of medical care is solved by doctors of a certain specialty and lawyers [8], in Ukraine these issues are dealt with by forensic experts, which is emphasized by our legislation [9, 10, 11].
However, in the presence of a complaint from relatives or other persons about poor quality treatment to the Ministry of Health, departmental inspections are carried out, where the commission of doctors of the Health Departments (HD) determines the correctness of medical care in a particular case. Only in the presence of a complaint to law enforcement agencies is a forensic medical examination appointed in the framework of criminal proceedings under Articles 139 and 140 of the Criminal Code of Ukraine. In order to accurately assess the correctness of medical care, in particular, obstetrics and gynecology, which is the most common among these examinations, it is necessary to analyze the most common defects and their causes.
Objective: taking into account the above, was to analyze the data of the State Statistics Service on maternal and infant mortality during pregnancy, childbirth and the postpartum period and compare it with the analysis of «Expert Conclusions» in cases of evaluation of obstetric and gynecological care. The obtained data were subjected to statistical processing by standard methods of descriptive statistics. During the statistical analysis of the commission forensic medical examinations of the Main Bureau of Forensic Medical Examination of the Ministry of Health of Ukraine regarding the obstetrics and gynecology profi le for 2013-2019, conducted personally, it was found that forensic medical examinations for medical care occupy 27.2% in the general structure of all commission examinations - (table 2).

RESEARCH RESULTS AND THEIR DISCUSSION
Forensic medical examinations for the provision of obstetric and gynecological medical care occupy a leading place in the overall structure of commission examinations for «medical cases» -23.1% (255 cases).
A detailed analysis of such examinations revealed that the average age of examined women was 31 years of age, ie of working age and childbearing age.
In these 255 examinations, defects in the provision of medical care were found by expert commissions in 186 cases, which amounted to 72.9%. And of these «defective cases» 62.9% (117 cases) of them were in direct causal connection with an adverse outcome; 35.5% (6 cases)some defects that were not causally related to the onset of fetal death. In 3 cases of gynecological examinations, there were discrepancies in the records in the medical records, which did not allow to assess the quality of medical care and the connection with the consequences.
83.9% (214 cases) were obstetric, and almost half of them, 47.7% (102 cases), had defects in the provision of medical care that were directly causally related to the adverse outcome. Of these, the commissions of experts identifi ed the following defects in the provision of medical care: 46.1% (47) of examinations, the defects in the provision of medical care were directly causally related to the death of the child; in 22.5% (23) -with extirpation of the uterus (severe injuries) and the onset   of fetal death; in 15.7% (16) -with the onset of severe consequences in both women and children (severe injuries in both); in 9.8% (10) -with central nervous system damage in a child (severe injuries); other cases (8): shortcomings during abortion in direct causal connection with the onset of severe consequences (removal of the kidney) -severe injuries and when untimely diagnosis of fetal malformations led to the impossibility of timely termination of pregnancy 15 examinations concerned neonatology, among which in most cases (10) there was a direct causal link between defects in medical care and the death of the child.
Of the defects, in all cases there were incorrectly chosen tactics of childbirth, as well as in most cases -125 cases out of 186 cases with defects (67.2%) -untimely provision or failure to provide medical care. The reason for the incorrectly chosen tactics of childbirth was underexamination of pregnant women, underestimation of survey data (for example, the case when a physiologically narrow pelvis doctor-obstetrician-gynecologist decided to «let in physiological childbirth», which resulted in death and serious injuries to the mother). In all these cases, doctors had a real opportunity to prevent serious consequences, as 98 cases occurred in large cities of Ukraine (the hospitals had all the necessary equipment and specialists).
When assessing the provision of medical care at different stages, it was found that at the pre-hospital stage (in the clinic) defects were allowed in 45 cases (24.2%), and at the hospital -in 141 cases (75.8%), in particular, during resuscitation measures.
When analyzing 255 of these examinations for obstetrics and gynecology, it was found that in the vast majority of cases -223 (87.5%) of all examinations for obstetrics received by the MB, contained the conclusions of departmental commissions of the HD.
Upon closer examination of such examinations and comparison of results, it was found that only in 51 cases (22.8%) there was a complete coincidence of the conclusions of the commissions of the Bureau of Forensic Medicine and the HD, and only in cases of signifi cant defects that were in direct causal connection with the consequences. In other cases, the departmental commissions of the HD did not fi nd defects in the provision of medical care, when, according to the results of forensic examinations, the defects were still present and led to serious consequences for women and / or children (death, serious injuries). It should be noted that the analysis of the conclusions of the HD commissions found that in almost all cases the commissions included doctors who were in one way or another connected with the accused medical workers (for example, were their supervisors or simply worked with them in the same institution).
At the same time, an analysis of 53 court verdicts according to the USRJU revealed that 13 of them were related to obstetrics and gynecology, and 12 of them were convictions [13]. In all cases, the source of evidence in the cases was exclusively the «Expert Conclusions», which clearly stated the existence of a defect in the provision of medical care, its connection with the consequence and the possibility of preventing this consequence.
It should be noted that in addition to the lack of a single algorithm of expert actions, which would be clearly indicated in the relevant document, complicate the forensic assessment of the quality of care such factors as: lack of certain protocols for care (eg, obstetric protocols in thrombosis and embolism during or after childbirth, etc.), which could facilitate forensic assessment of medical care in certain circumstances, poorly completed medical records of the victim, lack of information about the woman's health before pregnancy or the development of pathological conditions, electronic documentation.

CONCLUSIONS
1. In conducting our own research, it was found that forensic medical examinations for obstetrics and gynecology occupy a leading place in the overall structure of commission examinations for «medical cases», in the vast majority of examinations revealed defects in medical care were in direct causal consequential connection with an adverse consequence. This underscores the low level of obstetric and gynecological care in Ukraine.
2. A small percentage (22.8%) of the coincidence of the results of the commissions of the Bureau of Forensic Medical Examination and the Health Departments in cases of obstetric and gynecological medical care in Ukraine may be due to biased assessment of medical care by the commissions of the Health Departments, which violates the principles of impartiality and legality of assessment.
3. In our opinion, need to develop and implement in practice «Rules of forensic examinations in cases of bringing medical workers to justice for» professional offenses «by the relevant competent institutions (« Main Bureau of Forensic Medicine of the Ministry of Health of Ukraine «), and procedural regulation of the seizure of electronic medical records by law enforcement offi cials for forensic examination, which will improve the quality of such examinations in Ukraine and increase the level of detection of crimes in the fi eld of medical care. Актуальність. Інколи статистика лікарських помилок замовчується, а інформація про окремі інциденти стає відомою завдяки засобам масової інформації.