Trouver le dossier médical, prouver le préjudice moral

http://www.flickr.com/photos/dougww/922328173/Voici une affaire bien cocasse qui rappelle accessoirement les difficultés matérielles auxquelles les établissements de santé sont régulièrement confrontés lorsque, face à une demande aussi tardive qu’inattendue, il s’agit de retrouver le dossier médical d’un patient décédé qui est archivé depuis plus d’une quinzaine d’années.

Aux termes de l’arrêt du 14 novembre 2008, ((CAA Bordeaux, 14 novembre 2008, Mme P, n°07BX01758, AJDA 2009, p. 278.)) la Cour administrative d’appel de Bordeaux  a eu, en effet, l’occasion de se prononcer sur le cas d’une demande en réparation par une requérante du préjudice résultant de la perte du dossier médical de sa mère, décédée au centre hospitalier universitaire de Bordeaux le 15 novembre 1991.

La plaignante réclamait 15.000 € à titre de dédommagement pour le préjudice moral que lui aurait causé l’impossibilité de découvrir les circonstances exactes dans lesquelles sa mère se serait éteinte, et ce afin de permettre aux descendants d’accomplir leur travail de deuil.

Plusieurs enseignements peuvent être tirés de cette décision. Pour une bonne compréhension des enjeux de la décision, il est nécessaire de reproduire le considérant central :

« Considérant qu’il résulte de l’instruction que Mme X est décédée le 15 novembre 1991 au centre hospitalier universitaire de Bordeaux ; que Mme Y a demandé à consulter le dossier médical de sa mère en octobre 2005 ; que le centre hospitalier universitaire l’a toutefois informée que les recherches entreprises dans les archives n’avaient pas permis de retrouver le dossier ; que si Mme Y soutient que le décès est survenu dans des circonstances de nature à susciter le doute, et si elle invoque la nécessité d’obtenir des précisions sur les causes de la maladie, le traitement et les circonstances du décès de sa mère, elle ne fait état d’aucun trouble personnel pouvant expliquer le retard de 14 ans avec lequel elle a demandé à consulter le dossier médical de la défunte ; qu’en faisant encore valoir qu’en sa qualité de psychologue spécialisée dans l’analyse de l’histoire familiale, elle a démontré la nécessité de connaître les circonstances des décès familiaux pour permettre aux descendants d’accomplir leur travail de deuil de sorte que, « par respect pour ses patients », elle doit élucider les détails de la mort de sa mère, elle ne justifie pas non plus de l’atteinte à sa réputation ou à sa notoriété que lui causerait l’impossibilité de consulter le dossier médical en litige depuis plus de 14 ans après les faits ; qu’ainsi l’existence d’un préjudice moral réparable n’est pas établi par la requérante ; »

Les observations qui vont suivre se limiteront à la question de la communication du dossier médical et à la preuve du préjudice moral, sans évoquer la déchéance quadriennale.

Sur la communication des dossiers médicaux, on notera que les juges d’appel se sont fondés sur l’arrêté interministériel du 11 mars 1968 portant règlement des archives hospitalières, lequel détermine le contenu des archives hospitalières, le lieu de leur conservation, le personnel responsable de leur conservation et surtout la durée de leur conservation en fonction du contenu des dossiers médicaux.

En l’espèce, les recherches entreprises n’ont pas permis de retrouver le dossier médical considéré, ce qui ne surprend plus vraiment hélas, l’obligation légale et réglementaire s’étant  heurtée purement et simplement à un obstacle d’ordre matériel.

Incendies, inondations, regroupements ou fusions d’établissements ont parfois raison d’une partie des archives, sans qu’il soit besoin d’évoquer le vandalisme ou les termites. Cette question cruciale de l’archivage, trop souvent sous-estimée par les établissements faute de volontarisme ou faute de moyens et ce malgré les prescriptions réglementaires, met en jeu rien de moins que la mémoire vive des hôpitaux, à l’accès de laquelle leurs patients ont droit.

On peut d’autant plus être étonné que l’arrêté de 1968 prévoit, ou plutôt prévoyait une durée « ordinaire » de conservation des dossiers médicaux de vingt ans, prolongée jusqu’à 70 ans pour les dossiers concernant certaines pathologies (maladies chroniques, pédiatrie, stomatologie, neurologie) et de durée indéterminée pour les « dossiers d’affections de nature héréditaire susceptibles d’avoir des répercussions pathologiques ou traumatisantes sur la descendance ». Dans la pratique, ces délais sont, compte tenu du travail de sélection à accomplir selon les pathologies, en considération du flux annuel de patients et eu égard aux moyens matériels qui ne sont pas extensibles à l’infini, parfaitement irréalistes.

L’article R. 1112-7 du code de la santé publique, tel que modifié par le décret n°2006-6 du 4 janvier 2006, a introduit plus de souplesse et plus de pragmatisme, les nouvelles conditions de conservation et d’élimination étant rappelées par l’instruction interministérielle du 14 août 2007, lesquelles doivent faire l’objet d’une information auprès des patients.

Sur la preuve du préjudice moral, force est de constater que les juges d’appel n’ont pas été convaincus par la démonstration de la requérante, loin s’en faut. Il est difficile d’expliquer en quoi un trouble personnel pourrait être retenu face à la perspective d’ignorer les circonstances exactes du décès de sa mère lorsqu’on a attendu 14 ans avant de former une demande aux fins de consulter le dossier médical de la défunte. Cela relevait de la mission impossible.

Pour être réparable, un préjudice doit être certain, direct, personnel et actuel. Aucune de ces conditions n’était remplie. La douleur morale de la requérante n’a pas transparu avec évidence, considérant le nombre d’années qui se sont écoulées entre le décès et la demande de communication du dossier médical. Le fait pour la demanderesse d’évoquer un « respect pour ses patients », expression qui dénote à tout le moins une froideur dans les relations mère/fille et qui apparaît manifestement incompatible avec la démonstration d’un quelconque dommage moral, a sans doute achevé de convaincre les juges.

Affirmer n’est pas démontrer.

Omar YAHIA

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