НАСТОЯЩИЙ МАТЕРИАЛ (ИНФОРМАЦИЯ) ПРОИЗВЕДЕН, РАСПРОСТРАНЕН И (ИЛИ) НАПРАВЛЕН ИНОСТРАННЫМ АГЕНТОМ МЕЖРЕГИОНАЛЬНОЙ ОБЩЕСТВЕННОЙ ПРАВОЗАЩИТНОЙ ОРГАНИЗАЦИЕЙ “ЧЕЛОВЕК И ЗАКОН” ЛИБО КАСАЕТСЯ ДЕЯТЕЛЬНОСТИ ИНОСТРАННОГО АГЕНТА МЕЖРЕГИОНАЛЬНОЙ ОБЩЕСТВЕННОЙ ПРАВОЗАЩИТНОЙ ОРГАНИЗАЦИИ “ЧЕЛОВЕК И ЗАКОН”
The case in a process
2 April 2020
Names were changed for ethical reasons.
On 31 March 2017, Ekaterina gave birth to her child by caesarean
section at the Yoshkar-Ola Perinatal center. The birth was successful,
but the next morning the woman died on the operating table. Tragic
accident or medical staff negligence? The investigation has lasted for
years. In search of justice, Ekaterina's family applied to human rights
defenders of the organization "Man and Law".
The inaction of the doctors
On 17 March 2017, Ekaterina went to the Republican Perinatal center to
the department of pregnancy pathology. She was 35 weeks pregnant
and carrying twins. The doctors diagnosed a "threat of premature birth".
On 28 March, Ekaterina was diagnosed with an incorrect location of one
of the foetal. It was decided to perform a caesarean section.
On the morning of 31March, Ekaterina was transferred to the maternity
ward. The operation by caesarean section was performed by an
obstetrician-gynecologist A. E. At the end of the operation, a healthy boy
and girl were born. Blood loss in a woman in labor during surgery was
assessed by the doctor within the normal range. The happy mother was
shown her children. She called her mother, telling her that she had given
birth. Lyubov asked her daughter to tell her brother Sergei about the
good news. Ekaterina replied: "As soon as I get back on my feet, I'll call".
However, about an hour and a half later, Ekaterina called her mother in a
panic, saying that she had strong blood secretions. Lyubov comforted
her daughter, saying that doctors were nearby, they would help her. "Go
to church, stand and pray for me," Ekaterina begged. This was the last
conversation between mother and daughter.
Doctor A. E. examined the patient immediately after the operation at 09:
15 and estimated the amount of blood loss as moderate. Then he did a
check-up 45 minutes later at 10:00, and then at 11: 50. According to the
protocol of cesarean section treatment, the examination of the woman in
labor should be performed every 20-30 minutes for two hours after the
operation. Violation of the frequency of examinations led to a late
diagnosis of uterine bleeding.
For almost two hours, Ekaterina remained without medical supervision
and bled to death. Within a few hours, she lost 20% of her circulating
blood.
In the afternoon, doctors began conservative treatment, while with such
a significant blood loss, surgery was necessary. The chosen form of
treatment was ineffective, so at 16:00, the obstetrician-gynecologist A. E.
decided to amputate the uterus without appendages to stop blood loss.
All subsequent medical manipulations were an attempt to resuscitate
Ekaterina. However, they did not bring a positive result. On the morning
of 1 April, Ekaterina died on the operating table.
Violating the Federal law "on the basics of health protection of citizens of
the Russian Federation", medical staff performed the operation to
remove the uterus without concluding consent to perform the operation
with the patient or her relatives. Trying to protect himself, the doctor
forged a voluntary agreement to perform the operation on behalf of
Ekaterina and attached it to the medical history of the deceased.
Protracted investigation
On 10 May 2017, the Investigative Committee for Mari El Republic
opened a criminal case on the death of Ekaterina in the Yoshkar-Ola
maternity hospital. The criminal case was conducted under two articles:
forgery of an official document (article 327 of the criminal code, part 1)
and causing death by negligence due to improper performance of
professional duties by a person (article 109 of the criminal code, part 2).
However, the investigation process was suspiciously delayed. The
mother and brother of the deceased, realizing that the investigation had
reached a dead end, asked for help from human rights defenders of the
organization “Man and Law” to bring the perpetrators to justice.
In February 2018, human rights defender Sergei Poduzov prepared a
request for additional forensic examination on behalf of the victims. The
Investigative Committee granted the request. The examination was
carried out in the Bureau of forensic medical examination in Khanty-
Mansiysk, as a result of which no violations were found in the actions of
the medical staff of the perinatal center. However, the initial examination
from August to October 2017 was conducted by employees of the same
institution. Moreover, contrary to the investigator’s decision, experts from
Mari El Republic were involved in the examination.
On 7 May, Ekaterina’s relatives got acquainted with the results of the
next examination, which excluded the guilt of medical staff. And on 10
May, the investigator promptly closed the criminal case, despite the fact
that the fact of forgery of an official document by the doctor A. E. had
been established.
Sergei Poduzov together with Ekaterina’s relatives again appealed the
decision to terminate the criminal case and achieved its cancellation.
Since the autumn of last year, the investigation was resumed at the level
of the Investigative Committee of the Republic of Mari El and a third
forensic examination was appointed. This time the examination was
conducted in the Novokuznetsk clinical bureau of forensic medical
examination of the Kemerovo region. It lasted almost six months. This
time, the experts found violations.
Experts found that the negligence of medical staff had taken place even
at the stage of observation of the patient: not the full scope of the
examination, the need for prenatal hospitalization. But it was negligence
in the examination after the cesarean section operation that led to heavy
bleeding. Failure to provide medical aid became one of the causes of
Ekaterina’s death.
Despite the fact that the doctor's guilt had been established on both charges against him, on 6 August 2019, the Investigative Committee for Mari El Republic closed the case on the basis of the expiration of the Statute of limitations for criminal prosecution. However, the investigator did not consider the possibility of reclassifying two minor crimes (forgery of consent to perform an operation and causing death by negligence) to a medium one – negligence.
On 25 August, the human rights defender together with Ekaterina's
relatives once again appealed the decision to terminate the criminal
case. They demand to reopen the criminal case and charge the
obstetrician-gynecologist with negligence resulting in the death of a
person (293 of the criminal code of the Russian Federation, part 2), as
well as to bring to disciplinary responsibility employees of the
investigative department for ineffective and untimely investigation of the
case.
For more than two years, the employees of the investigative department
conducted a preliminary investigation. Without constant complaints from
victims, the investigation did not progress. The evidence of guilt was
overlooked.
It is hard for the family to go through the sudden death of Ekaterina. Her
mother and father have lost their health, and now they live alone in the
countryside, because they can't bear to see young girls walking with
their children. "No one will ever cure the heartache that is in my heart
after the death of my daughter," writes Ekaterina's mother. Nevertheless,
she does not give up hope of achieving a fair trial.
New round of the case
In March 2020, the Yoshkar-Ola city court of the Republic of Mari El
issued a decision on compensation for non-pecuniary damage to
Ekaterina’s mother in the amount of 400 thousand rubles.
The investigative department of the Investigative Committee of Russia
for Mari El Republic issued a decree to eliminate actions that led to the
crime by the official person that caused the death of a person. The
decree contained a list of violations committed by the Republican
Perinatal center. It was sent to the Ministry of Health of Mari El Republic
for further elimination of violations.
Human rights activists plan to appeal the decision of the Yoshkar-Ola
city court regarding the amount of compensation for non-pecuniary
damage.