Supreme Court Confirms Not Guilty Verdict for 7 Medical Staff in Ewha Mokdong Hospital Newborn Mass Death Case

[Asia Economy Reporter Choi Seok-jin, Legal Affairs Specialist] The acquittal of seven medical staff members prosecuted in connection with the 2017 'Ewha Mokdong Hospital Neonatal Mass Death' case has been finalized.

The Supreme Court's 2nd Division (Presiding Justice Min Yoo-sook) recently confirmed on the 30th the lower court's verdict acquitting all seven defendants, including a professor of pediatrics and nurses at Ewha Mokdong Hospital, on charges of professional negligence resulting in death.

The court stated, "Even if the victims in this case all died simultaneously from sepsis caused by Citrobacter freundii, the evidence submitted by the prosecution alone did not prove beyond reasonable doubt that the injections administered to the victims were contaminated with Citrobacter freundii, nor that such contamination occurred due to the preparation (dividing the appropriate dosage into syringes) and delayed administration of the injections in this case."

It continued, "Therefore, the lower court maintained the first trial's judgment of not guilty due to lack of proof of the crime regarding the charges against the defendants," and explained the reason for dismissing the prosecution's appeal was that "the lower court's judgment did not violate the rules of logic and experience, nor did it exceed the limits of free evaluation of evidence or violate the rules of evidence."

The 'Ewha Mokdong Hospital Neonatal Mass Death' case refers to the incident on December 16, 2017, when four newborns being treated in the neonatal intensive care unit incubators at Ewha Mokdong Hospital died from infection-induced sepsis.

The four newborns, who had received lipid nutrition injections (Smoflipid) the day before their deaths, sequentially went into cardiac arrest between 5:44 PM and 9:08 PM the following day. Despite medical staff attempting cardiopulmonary resuscitation, all four newborns died sequentially within approximately 80 minutes starting around 9:30 PM.

The prosecution judged that the injections were contaminated with Citrobacter freundii due to the nurses' negligence, leading to the newborns' deaths from sepsis, and indicted the nurses on charges of professional negligence resulting in death.

Additionally, the head of the neonatal intensive care unit and the pediatrics professor were also indicted on charges of professional negligence resulting in death for their supervisory responsibilities over the nurses. During the investigation, the police applied for arrest warrants for the involved parties; while the warrants for the nurses were dismissed, three professors were detained.

The police and prosecution confirmed that, for insurance processing purposes, one vial of Smoflipid?which should be administered to one patient only?was divided and administered to multiple patients, and that the injection, which requires refrigeration at 2?8 degrees Celsius and immediate use after opening, was left at room temperature for over five hours. Citrobacter freundii was commonly detected in the bodies of the deceased newborns and the syringes.

However, both the first and second trial courts acquitted all seven defendants.

Although the medical staff failed to fulfill their duty of care in infection control, the prosecution's evidence was insufficient to prove that such negligence caused the newborns' deaths, i.e., the causal relationship was not established.

Evidence included that the bacteria were not detected in other newborns who received the same injection, and expert opinions that could not completely exclude the possibility that the deceased newborns were infected through other routes.

The first trial court stated, "Unless it is proven beyond reasonable doubt that the Smoflipid administered to the victims was contaminated with Citrobacter freundii, it is difficult to conclude beyond reasonable doubt that the negligence in preparing the Smoflipid led to its contamination with Citrobacter freundii, and that this caused the victims to develop sepsis from Citrobacter freundii resulting in death, as alleged in the indictment."

Regarding the prosecution's claim that the medical staff's failure to timely check the stool culture results of one deceased newborn caused the death, the first trial court also concluded, "Based solely on the evidence submitted by the prosecution, it is difficult to conclude beyond reasonable doubt that death was influenced by a weakened immune system due to rotavirus infection."

The second trial court reached the same conclusion.

The second trial court stated, "This case involves four victims hospitalized in the same neonatal intensive care unit who died almost simultaneously from the same cause, making it an extremely rare case with few precedents," but added, "While this may be a reason to punish the involved parties and hold them strictly accountable, it is also a circumstance requiring careful judgment to avoid relying on emotion and intuition rather than legal principles and evidence."

Furthermore, the second trial court pointed out, "The indictment in this case is fundamentally based on inference, and it adopts and combines only unfavorable possibilities for the defendants while excluding favorable ones. To establish professional negligence resulting in death as a predictable accident rather than an unforeseen misfortune, strict evidence evaluation according to criminal trial principles is necessary."

The second trial court stated, "There are significant alternative possibilities besides the contamination of Smoflipid with Citrobacter freundii on December 15, and even if the Smoflipid was contaminated on that date, it is difficult to definitively conclude that this contamination resulted from the preparation and delayed administration in this case. Therefore, a guilty verdict cannot be based solely on the goodwill of state agencies and the relative superiority of possibilities."

It added, "In summary, even if the victims all died simultaneously from sepsis caused by the same Citrobacter freundii, unless the prosecution proves beyond reasonable doubt that the infection source?the contamination of Smoflipid with Citrobacter freundii on December 15 and that such contamination resulted from the preparation and delayed administration in this case?there is no proof of the indictment regardless of the defendants' negligence."

The Supreme Court also found no problem with the lower courts' judgments.

This content was produced with the assistance of AI translation services.