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Incompletezza della cartella clinica e responsabilità medica

Posted on April 14, 2018 at 8:35 AM

Fonte: AIOP Annagiulia Caiazza, Ufficio giuridico-sanitario Sede nazionale Aiop

Cassazione civile, sentenza n.7250 del 23 marzo 2018

Con la sentenza n. 7250 del 23 marzo 2018 (allegata), la Corte di Cassazione ha affermato il principio in base al quale l'incompletezza della cartella clinica va ritenuta circostanza di fatto che il giudice di merito può utilizzare per ritenere dimostrata l'esistenza di un valido nesso causale tra l'operato del medico e il danno patito dal paziente.

La decisione è intervenuta a conclusione di una vicenda in cui una paziente, inizialmente recatasi presso una struttura ospedaliera per una mal occlusione dentale, era andata incontro ad un peggioramento consistito nella perdita dei denti e nel deterioramento della situazione occlusale, con persistenti dolori e lesioni. A fronte di tale situazione si era quindi reso necessario un intervento chirurgico al fine di spostare il mascellare, al termine del quale la paziente veniva dimessa «con la bocca in contenzione, la faccia tumefatta, l'impossibilità di masticare e un blocco mascellare per 45 giorni».

A fronte della richiesta di risarcimento proposta dalla paziente, i giudici di primo e secondo grado avevano respinto l'istanza ritenendo che l'onere della prova circa la sussistenza di un nesso eziologico tra le varie terapie prestate dai sanitari alla paziente in un arco decennale asseritamente incongrue e non corrette e il peggioramento della salute dell'appellante, incombeva a quest'ultima e che tale onere non fosse stato assolto.

Ricorrendo in Cassazione la paziente aveva lamentato il fatto che la lacuna probatoria era da imputare allo smarrimento da parte dei sanitari, della documentazione sanitaria relativa alle terapie somministratele e quindi alla difettosa tenuta della cartella clinica.

La Corte di Cassazione ha quindi accolto il ricorso rilevando come ricada sulla struttura sanitaria l'onere di redigere una cartella in ordine e completa in modo da poter acclarare eventuali negligenze o imperizie da parte dei sanitari oppure scagionarli per aver comunque seguito la best practice ma senza risultati. A fondamento della decisione, la Corte ha richiamato l'ormai consolidato orientamento della giurisprudenza di legittimità, in base al quale «l'ipotesi di incompletezza della cartella clinica va ritenuta circostanza di fatto che il giudice di merito può utilizzare per ritenere dimostrata l'esistenza di un valido nesso causale tra l'operato del medico e il danno patito dal paziente, operando la seguente necessaria duplice verifica affinché quella incompletezza rilevi ai fini del decidere ovvero, da un lato, che l'esistenza del nesso di causa tra condotta del medico e danno del paziente non possa essere accertata proprio a causa dell'incompletezza della cartella; dall'altro che il medico abbia comunque posto in essere una condotta astrattamente idonea a causare il danno, incombendo sulla struttura sanitaria e sul medico dimostrare che nessun inadempimento sia a loro imputabile ovvero che esso non è stato causa del danno, incombendo su di essi il rischio della mancata prova» (Cass. civ. n. 12218 del 12 giugno 2015).

Categories: Responsabilità Medica, Sentenze Cassazione

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