Defendant 1 and one other

Prosecutor

Hospital:

Attorney Shin-ho et al.

Seoul Central District Court Decision 2006Gohap5987 Decided June 8, 2007

All appeals filed by the prosecutor against the Defendants are dismissed.

1. Summary of grounds for appeal;

In full view of the time period during which the Defendants had followed the direction of the rule, when the Defendants had taken active measurements twice against the victims, when the conditions of cardiopulmonary suspension due to internal blood transfusion occurred, when the operation of dynasium medication was conducted, and the function and importance of the dynasium measurements in the operation of dynasium, the Defendants were found to have causation between the Defendants’ failure to properly measure active dynasium and the result of the victims’ death at the latest, and the Defendants’ failure to take countermeasures against emergency situations was found to have been found guilty, and the lower court found the Defendants not guilty, thereby adversely affecting the conclusion of the judgment.

2. Summary of the facts charged

On November 2, 2005, the Defendants: (a) were hospitalized by Nonindicted Party 2, who was subject to duplicating treatment at the above general hospital room on November 2, 2005 on the part of the Defendants, on the 20th day after the aftermath of death; (b) Non-Indicted Party 1 (the Nonindicted Party in the judgment of the Supreme Court) determined that the 15th day after the 1st day after the 2nd day after the 1st day after the 1st day after the 1st day after the 1st day after the 1st day after the 2nd day after the 1st day after the 2nd day after the 1st day after the 1st day after the 1st day after the 2nd day after the 1st day after the 1st day after the 1st day after the 1st day after the 1st day after the 1st day after the 1st day after the 1st day after the 1st day after the 1st day after the 1st day after the 2nd day after the 2nd day after the 1st day after the f.

3. The judgment of the court below

The lower court acquitted the Defendants of the death of the victim Nonindicted 2 on the ground that there was no negligence as described in the facts charged, and there was no other evidence to acknowledge it, under the latter part of Article 325 of the Criminal Procedure Act.

4. Judgment of the court below

(a) Facts of recognition;

In full view of the records, the following facts may be acknowledged in light of the Defendants’ respective original judgment and the first instance court’s legal statement, Nonindicted 3’s legal statement in the lower court, the police and the prosecutor’s protocol against the Defendants, and Nonindicted 3 and 1 of the witness, the results of the lower court’s entrustment of the medical record appraisal to the Korea Medical Association, the Korea Medical Association for Samsung Seoul Hospital, and the results of the fact-finding inquiry to the Samsung Seoul Hospital.

(1) On October 31, 2005, the victim non-indicted 2 was hospitalized in the Seoul Alternative Hospital on November 2, 2005 to remove the dysty from the two parts of the dystyp, and then received dyspical dyspical dyspical dyspical dyspical dyspical dypical dypicals around November 12, 2005. The operation

(2) After the operation, the victim was transferred to the recovery room, and the active symptoms, such as blood pressure, body temperature, beer, and respiratory, were stable, and the victim was transferred to the general hospital around 20:15.

(3) Upon the transfer of the victim, Defendant 1, the nurse in charge of the general sick room, measured the vitality by using mechanical devices, such as blood pressure gauge, body temperature gauge, and panscule, and measured the vitality by the same method in around 21:30. At the time, the victim’s blood pressure, body temperature, beer, and respiratory were within the normal range.

(4) Around 22:15, the chief medical doctor, the main medical doctor, etc. had taken a medical examination. At the time, the victim did not have any special symptoms to suspect the blood transfusion in a stable state, such as the victim’s name with respect to the food, and the quality of the jury’s quantity without the blood transfusion.

(5) Defendant 1, as seen above, conducted two times of measurement of activeness using mechanical equipment as seen above. At around 21:00, Defendant 1: (a) checked the state of the victim in the sick room when the victim complained of her heart; (b) ceased to administer her active control in order to reduce her heart; (c) checked the operation level in the sick room; (d) observed the quantity and quantity of her part, the quantity of her part, the quantity of her part, the form of her part, the food, and the state of her part, etc. through T-selfcos; and (e) observed the victim who complained of her part and the her part of her part, and confirmed her part of her part, around 22:00. Moreover, Defendant 1, who was up to 23:100 prior to his working hours, observed the rate of the number of her part in the sick room, the patient’s body temperature, the change of her body temperature, the amount of her part, etc., but did not find any special symptoms suspected for the victim.

(6) From 23:00 to 22:50, Defendant 2, who was scheduled to work, administered a medical control on behalf of the victim complaining of the surgery pain. At around 23:00, at around 23:0, Defendant 2 again measured the amount of urine in the sick room, looked at the state of the victim, and inspected the amount of urine, but did not find any special circumstances. Defendant 2 was informed of the doctor in charge according to the contact between the bereaved family and the bereaved family members that the victim does not suffer from concealment while measuring the urgical symptoms for the patients in the sick room after 23:35, the medical team conducted pulmonary resuscitation and re-operation, but the victim died at around 02:49 of the following day.

(7) Meanwhile, at the time of the operation, the captain measured the 15 minutes of the operation with respect to nurses until the stability of the state of the nurse, and issued an instruction to measure the virative condition once every four hours after the operation, and then every four hours after the operation.

B. Determination

앞서 인정한 사실과 기록에 의하여 인정되는 다음과 같은 사정들, 즉, ① 피고인들은 피해자가 병실로 이송되어 온 2005. 11. 2. 20:15경 및 21:30경 2회에 걸쳐 활력징후를 측정하였는데(결국 1시간 간격의 활력징후 측정을 하라는 의사의 지시에 대하여 22:30경 측정을 하지 않았을 뿐이다), 이때 피해자의 활력징후는 정상범위 내였고, 22:15경 의사회진시에도 피해자에게 별 다른 이상이 발견되지 않았으며, 회진 이후에도 피고인들은 여러 차례 병실에 들어가서 피해자의 상태를 확인하였으나, 췌장 수술 후 내출혈을 의심할 만한 복부팽만이나 수술부위와 연결된 배액관으로 나오는 배액의 색깔 변화 등 특이증상은 발견되지 않았던 점, ② 23:50경 피해자에 대하여 심폐소생술이 시행될 때 최초로 배액관에서 다량의 혈액이 관찰되었고, 다음 날 01:20경 재수술을 위하여 개복하였을 때 복강 내에 약 3L 가량, 기관지 삽관부위에서도 1L 이상의 출혈이 발견되었는데, 피해자는 복부팽만도 그리 심하지 않았고, 이와 같은 출혈량은 이 사건과 같이 단시간 내에 심폐기능정지에 이를 정도는 아니었으며, 이에 집도의였던 공소외 3은 피해자의 사망원인으로 수술 후 다량의 출혈이 가장 큰 비중을 차지하나 피해자의 원 병명인 췌장 소마토스타틴종이라는 희귀질환과 관련되었을 가능성이 있는 당뇨성 비케톤성산증과 그에 따른 전신 상태의 악화, 출혈 성향, 혼수 등이 환자의 상태를 악화시키고 복잡하게 하여 치료에 반응하지 않고 사망에 이르게 하는데 기여했을 가능성이 있다고 판단한 점, ③ 대한의사협회에 대한 원심의 진료기록감정촉탁결과 및 당심의 사실조회결과에 의하면, 피해자의 사망원인은 원인을 알 수 없는 범발성 출혈에 의한 것으로 판단되는데, 이 사건과 같이 피해자가 1차 수술 전에는 출혈성 소인이 없거나 발현되지 않다가 2차 수술 전에 출혈성 소인이 나타나는 경우는 매우 드문 경우로서 이는 수술 전에 흔하게 시행하는 검사로는 잘 감지되지 않는 경우도 있어 사건에 출혈성 경향을 완전히 예측하거나 방지하는 것이 불가능하다고 할 수 있으며, 이는 흔히 수술부위에서 출혈이 있는 경우 그와 연결된 배액관을 통해 이를 알 수 있으나 그 외 부위에서 출혈이 있는 경우에는 복강이 혈액으로 찬 이후에야 배액관을 통해 내출혈이 있음을 알 수 있다는 것과 피해자 사망 직후 개복한 결과 소장, 장간막, 유문하정맥, 간문맥 등에서 전반적으로 피가 스며나왔다는 것으로 뒷받침되는 점, ④ 주치의가 피고인들에게 내린 활력징후 측정지시는, 수술 전에 일괄적으로 내리는 지시로 상태 안정 후 4시간 동안 1시간마다 측정하라는 지시는 환자가 중환자실로 들어가는 경우에 대비한 것이며, 회복실에서 일반병실로 올라오는 환자의 경우에는 그와 같은 정도의 측정은 필요하지 않고, 환자의 상태에 따라 구두로 지시를 변경하기도 하며, 피해자의 주치의 공소외 1도 수사기관에서 피해자가 일반병실로 올라온 후 측정된 2회의 활력징후 측정결과나 2회째 측정 후 약 40분 후에 있었던 회진결과, 기타 배액관 확인결과 등에 비추어 볼 때 피해자와 같은 경우 1시간마다 활력징후 측정이 필요한 환자는 아니었고 간호사들의 요청이 있었다면 4시간마다 측정하는 것으로 지시를 변경하였을 것이라고 진술하고 있어, 피고인들이 활력징후 측정에 관한 의사의 지시를 제대로 준수하지 않았다 하더라도 수술내용, 환자의 상태 등에 비추어 피해자와 같은 환자들에 대한 통상적인 활력징후 측정의 실시범위를 크게 벗어난 것으로는 보이지 않는 점, ⑤ 서울대병원 외과병동의 ‘외과간호사를 위한 지침서’에 따르면, 췌장 수술 환자의 경우 4시간마다 활력징후를 측정하여야 한다고 되어 있고, 간호사 1명이 17명 정도의 환자를 담당하고 있는 서울대병원 일반병실의 의료여건상 간호사는 의사의 특별한 지시가 없는 한 4시간마다 활력징후를 측정하는 것이 임상관행인 점 등에 비추어 보면, 피고인들이 1시간 간격으로 피해자의 활력징후를 측정하지 않았고 피해자가 그 후 사망하였다는 사정만으로, 피고인들에게 의사의 지시를 어기고 활력징후를 측정하지 아니하여 피해자의 혈압저하 상태를 발견하지 못함으로써 피해자를 사망에 이르게 한 업무상 과실이 있었다거나 피고인들의 활력징후 측정 미이행 행위와 피해자의 사망 사이에 인과관계가 있었다고 단정하기 어렵고, 달리 이를 인정할만한 증거도 없다.

Therefore, the judgment of the court below which acquitted the Defendants under the latter part of Article 325 of the Criminal Procedure Act on the ground that each of the facts charged in this case against the Defendants constitutes a case where there is no proof of crime, is just, and the prosecutor'

5. Conclusion

Therefore, since the appeal by the prosecutor against the defendants is without merit, it is dismissed in accordance with Article 364 (4) of the Criminal Procedure Act. It is so decided as per Disposition.

Judge Cho Yong-dae (Presiding Judge)