After a fatal accident in healthcare, healthcare institutions are usually not prosecuted criminally. This is evident from research by Pointer and De Gelderlander. Pointer investigated 58 fatal incidents from the past 17 years. Many of these did not come to trial. Two cases from Eindhoven did, but one resulted in an acquittal and the other a conditional fine after a ten-year trial.
A fatal accident in a healthcare institution does not automatically come to court. The Public Prosecution Service (OM) first conducts an investigation and then decides whether the matter will be brought before a judge. According to the Public Prosecution Service, the Public Prosecution Service has 58 fatal cases in youth care, disability care and elderly care Pointer 30 examined. Thirteen of these have been brought to trial.
Acquitted in fatal accident in Eindhoven
Since 2009, no more than four healthcare institutions have been taken to court for fatal incidents. The first was Lunet Zorg in Eindhoven in 2009. A 40-year-old man was seriously injured at the Eckartdal location while he was in a seclusion room. The man had set a fire there. He eventually died in hospital from his burns.
According to the public prosecutor, the fatal accident could have occurred due to ‘a combination of shortcomings and negligence’, but the judge disagreed. It was acquitted.
Janneke died in GGzE
Another fatal accident in Eindhoven came to court in 2013. That year, 29-year-old Janneke was admitted to the Emergency Psychiatry Department of Mental Health Care Eindhoven (GGzE). She had serious psychological complaints and was given the drug clozapine. That drug would have been administered by a doctor in training.
Janneke died a month later. Research showed that she was hypersensitive to this medicine and that this caused her heart muscle to become infected. It then took ten years until a final ruling was reached in the case.
On appeal, the court ruled that ‘the institution failed to fulfill its obligation to provide the necessary medical assistance in a timely manner’. At several times there would have been signals that should have prompted the institution to act differently. According to the court, the woman’s death is therefore attributable to the GGzE.
The institution was imposed a conditional fine of 19,500 euros. GGzE therefore only has to pay that amount if it makes the mistake again. This statement was incomprehensible to Janneke’s parents. “It’s ridiculous,” Janneke’s mother responded at the time.
‘Structural shortcomings in healthcare’
The two Eindhoven cases have been dealt with, but in most cases it does not get that far. “The Public Prosecution Service should prosecute healthcare institutions much more often for gross negligence,” says Olga Floris, health law teacher and chairman of Whistleblowers for Disabled Care to Pointer. “Despite structural shortcomings in healthcare, there is hardly any prosecution.”
In addition to fire and problems with medication, the cases investigated also involved drowning, suffocation, overdoses, suicide or a fall. Five clients died after emergency workers brought them to the ground in a restrained position.
It also appears that the Healthcare Inspectorate does not keep figures for unnatural deaths. Healthcare institutions must report a death to the inspectorate themselves and will then be instructed to conduct their own investigation. According to Floris, our healthcare system is stuck in this. “As a result, people die unnecessarily and often do not receive the right care.”
