A recent complaint from Ms. He, a resident of Guan County in Shandong, highlighted a tragic incident that resulted in the death of her father due to what she described as an unnecessary medical procedure. Last summer, her father was receiving treatment for a cerebral infarction at Guan County People’s Hospital when doctors suggested he undergo a DSA brain angiography. Unfortunately, during the procedure, there was an extravasation of contrast agent which led to her father’s passing.
According to Ms. He’s account of the events, her father, Mr. He (alias), visited the hospital on May 23, 2025, due to feeling unwell. Upon admission, although he had some mobility issues, his condition was relatively stable. The hospital diagnosed him with cerebrovascular disease and type 2 diabetes. Subsequent MRI scans revealed multiple ischemic lesions, infarctions, softening zones in the brain consistent with arteriosclerosis, and a severe narrowing or occlusion possibility in the right anterior cerebral artery.
Ms. He mentioned that her father showed signs of improvement after receiving intravenous fluids in the hospital. “He was able to walk and talk normally, even taking walks with my mother.” However, despite these positive developments, the doctors suggested a DSA brain angiography to further investigate the underlying causes. When asked about the risks by the family, the doctors downplayed it as a minor procedure without disclosing that it was a minimally invasive surgery.
On the morning of May 25, after the family signed the consent form, Mr. He underwent the procedure on his own accord. However, he experienced symptoms like vomiting afterward, and a CT scan revealed contrast agent extravasation. He was transferred to the neurology department of Liaocheng City Hospital for a craniotomy that same afternoon. Despite subsequent transfers to Shandong Provincial Center for Disease Control and Prevention and back to Guan County People’s Hospital, his condition deteriorated continuously, eventually leading to his passing on July 1.
On August 6, the Shandong Dongyue Forensic Appraisal Center’s evaluation attributed Mr. He’s death to “contrast agent extravasation leading to cerebral edema, cerebral infarction, brain herniation, postoperative cerebral hemorrhage secondary to lung infection, diffuse peritonitis, and ultimately multiple organ dysfunction syndrome.”
Subsequently, on September 5, a hearing was convened by the appraisal center, incorporating statements from both medical professionals and the family, along with medical records. The final conclusion determined that the choice of performing a comprehensive cerebral angiography on a high-risk patient with diabetes was medically inappropriate. During the angiography, the patient exhibited abnormal symptoms such as restlessness, staring, and loss of limb movement, for which the hospital failed to promptly discontinue the contrast agent, causing further harm to the patient. Although the family signed an informed consent form, there were shortcomings in adequately informing them of the risks beforehand.
The appraisal center’s ultimate finding was that the occurrence of the complications leading to the patient’s death was closely related to both medical malpractice and the patient’s intrinsic factors, as well as the peculiarities of cerebral disease caused by the contrast agent. They suggested that the contribution of fault from both parties was essentially equal, with a proposed split of responsibility at 45%-55%.
Nonetheless, the family does not agree with the allocation of fault. Ms. He believes that her father should not have been put at such risk and only underwent the examination based on the hospital’s recommendation, holding them more accountable for the outcome.
Ms. He also claimed that the hospital did not provide complete electronic data to the appraisal organization, citing damage to monitoring video footage and the overwrite of monitoring equipment data. Currently, the family has lodged a complaint with the Guan County Health Bureau regarding the sealing of the medical records.
However, as per reports, to date, the Guan County Health Bureau has yet to disclose the administrative penalties resulting from this medical accident.