No prosecution after patient death in hospital

The Public Prosecution Service decides not to prosecute after the tragic death of a 3-year-old patient at Juliana Childrens Hospital. The patient suffered oxygen deprivation because a tube of the ventilator was incorrectly connected. After extensive investigation, the Public Prosecution Service concluded that it cannot be determined who caused this and that the involved anesthesia staff did not act culpably.

The boy was scheduled for surgery on March 30, 2023, at Juliana Childrens Hospital in The Hague. Shortly after being put under anesthesia, things went wrong: ventilation did not start, leading to a resuscitation situation. The involved healthcare workers assumed a so-called bronchospasm, a tightening of the muscles around the airway, and tried everything to fix this presumed problem. At some point, it became clear that a tube of the ventilator was incorrectly connected, which was the cause of the boy not receiving oxygen. Two days later, the boy died from the resulting oxygen deprivation.

Following the death, a criminal investigation was launched into possible culpable conduct by the anesthesia staff. The investigation revealed that three similar surgeries had been successfully performed that morning using the same ventilator. Despite extensive investigation, it was not clarified at what moment after the third surgery the ventilator tube came loose and who subsequently reconnected it incorrectly. The involved anesthesia staff stated that before putting the boy under anesthesia, they were not aware that the tube had come loose. This knowledge could also not be derived from other investigative findings.

They also stated that due to the earlier successful surgeries that day and information visible on the ventilator screen, they had no reason to doubt the correct functioning of the device. During the investigation, it was found that during resuscitation, information on the ventilator screen indeed appeared to indicate proper oxygen circulation. The Public Prosecution Service therefore judges that the operating room staff cannot be held criminally liable. They have been informed by the public prosecutor that the cases against them have been dismissed. The boys parents have also been notified of this decision.

The Public Prosecution Service has concluded that the boys death is the very tragic result of an exceptional situation. The hospital has taken measures to prevent this from happening again.