Désorganisation du service et responsabilité pénale

Les faits remontent à février 2003 mais ils n’en demeurent pas moins dramatiques. Pour une parfaite compréhension des données du litige, ils méritent d’être précisément relatés.

Le 9 février 2003, vers 23h, une dame, entraînée par son chien qu’elle tenait en laisse et qui pourchassait un chat, a fait une lourde chute de sa terrasse, qui surplombait un terrain en contre-bas, en tombant d’une hauteur de 2m et en entraînant avec elle une jardinière en pierre d’environ une centaine de kilos. Elle s’est relevée, a regagné son domicile et s’est allongée.

Le lendemain, son beau-père qui résidait avec elle, a fait appel à sa voisine, laquelle a, dans un premier temps, contacté le médecin traitant de la victime mais celui-ci lui a indiqué qu’il se déplacerait ultérieurement en fonction de son travail au cabinet.

Vers 11h20, la voisine a de nouveau appelé le médecin de famille de la victime, dont le secrétariat lui a dit qu’il se déplacerait en fin d’après-midi. Elle a alors décidé de recourir à son propre médecin traitant, lequel est arrivé vers 12h45.

Sur place, le praticien a décrit au médecin régulateur un état alarmant de la patiente, et une équipe médicalisée a été envoyée.

Arrivé sur place à 13h32 avec un véhicule de transport des pompiers, le médecin volontaire des pompiers, le Docteur BE, a posé un diagnostic moins alarmiste que celui du médecin traitant, en retenant des côtes cassées sans gravité ainsi qu’un emphysème sous-cutané latéral. Aussi a-t-il demandé, en accord avec le médecin régulateur du SAMU, un transport simple vers le centre hospitalier Saint-Roch de Nice pour un bilan radio.

Le Docteur BE aurait remis au chef d’agrès pompier (pompier responsable de la planification et de la gestion des activités du personnel armant son véhicule) chargé du transport, l’original du feuillet portant son diagnostic, qui en principe doit être remis lors de l’arrivée au centre hospitalier. La dame aurait été placée dans une coquille en position semi-assise pour faciliter son transport.

L’ambulance des pompiers est arrivée au centre hospitalier Saint-Roch à 14h07 au service des urgences. La patiente a été prise en charge par l’infirmière d’accueil et d’orientation (IAO) ((Certains préfèrent substituer le mot « organisation » au mot « orientation », au motif que l’orientation du patient relèverait des prérogatives du médecin.)), à qui les pompiers auraient seulement remis le document par eux rempli faisant état d’une suspicion de fractures de côtes sans le certificat médical du médecin volontaire.

Au regard de ce document et de l’état apparent de la patiente, l’IAO l’a placée en position P4 non urgent, l’infirmière ne s’étant pas occupée de la patiente jusqu’à ce qu’elle quitte le service à 14h50.

Il faut savoir que 4 positions pour la prise en charge des patients sont en vigueur dans cet hôpital, selon la nature des blessures ou des affections :

  • P1: prise en charge immédiate
  • P2 : prise en charge dans la demi heure
  • P3 : prise en charge dans l’heure
  • P4 : prise en charge dans les 2 heures.

A ce moment, le médecin senior du service où était affecté un interne (Docteur BA), le Docteur Sylvie L. quittait, avec l’autorisation de son supérieur hiérarchique, Monsieur DE, prématurément le service pour raison de santé.

Le Docteur DE, qui dirigeait le service d’accueil et de traitement des urgences, aurait, selon ses déclarations, demandé à l’interne T qui faisait fonction d’interne et qui travaillait à l’étage supérieur dans un autre service, d’aller renforcer sa collègue le Docteur BA, seule présente au service à ce moment-là. Aux dires du Docteur BA, en cas de problème, il devait être fait appel au Docteur TA, médecin senior.

Et selon le Docteur DE, il aurait informé les trois autres médecins seniors dans leur service respectif, d’être à la disposition des urgences, ce qui n’avait été confirmé par aucun d’eux.

Vers 14h30-14h45, le Docteur TO, qui a déclaré ne pas se souvenir si le Docteur DE lui avait demandé de renforcer le service des urgences, passait dans le service des urgences, pour aller, selon elle, chercher son sac laissé dans un box, lorsqu’elle fut interpellée par la voisine de la patiente qui l’accompagnait afin qu’elle vienne voir cette dernière qui souffrait énormément.

Le Dr. TO a fait placer la patiente dans un boxe, l’a auscultée sans approfondissement, sans avoir vu son dossier médical, selon sa première déclaration, mais elle a précisé par la suite que ce dossier était vide et que si elle avait eu ces informations, elle aurait envoyé la patiente en soins prioritaires, et lui a fait administrer des médicaments et prescrit un bilan radiologique.

Le Dr. TO a déclaré n’avoir pas eu le réflexe de recueillir les renseignements inscrits sur informatique, s’étant par la suite rapprochée de l’interne, le Dr. BA, qui selon elle revenait de déjeuner (allégation contestée par l’intéressée qui déclare avoir toujours été présente dans le service à compter du départ du Docteur Sylvie L., médecin senior) pour l’informer verbalement de son action et aurait quitté le service des urgences pour rejoindre le sien. Cette transmission d’informations était contestée par le Dr. BA. qui soutenait qu’il appartenait à sa collègue de poursuivre les soins donnés à la patiente.

A 15h35, la patiente a été conduite au service de radiologie. Elle en est revenue à 16h13. A 16h45, elle se plaignait de fortes douleurs ; Mme AR, infirmière, en informait l’interne, le Dr. BA, laquelle lui indiquait que cette patiente était suivie par le Dr. TO que Mme AR tentait de joindre.

A 16h50, l’état de santé de la patiente se détériorait : le Dr. BA se rendait à son chevet, lui prescrivait des antalgiques (Perfalgan et morphine), la pose d’une voie veineuse, ainsi qu’un examen sanguin et procédait à un examen clinique qui lui révélait un pneumothorax confirmé par l’examen des clichés.

Après la pose de la prescription, la patiente semblait aller mieux et l’infirmière, Mme AR, s’est alors occupée d’un autre patient.

Le Dr. TO, précédemment appelée par l’infirmière à la demande du Dr. BA alors qu’elle se trouvait dans son service, à l’étage supérieur, et donnait des soins urgents à une patiente, s’est aussitôt rendue après dans le service des urgences où elle a rencontré le Dr. BA, laquelle lui a remis les radios en lui signifiant qu’il s’agissait de sa patiente et qu’elle avait fait une piqûre de morphine.

Après avoir pris connaissance des radios, le Dr. TO est retournée dans son service voir un chirurgien thoracique, et, sur les conseils de ce dernier, a appelé le service des scanners qui lui a indiqué qu’il pouvait prendre la patiente dans les 15 minutes.

Elle est redescendue à nouveau dans le service des urgences et a constaté que l’équipe de réanimation prenait en charge la patiente dont l’état s’est aggravé vers 18h, à la suite d’une perte de connaissance. L’infirmière, Mme AR, avait alors sollicité l’intervention du Docteur TA, médecin senior de l’UHCD (unité d’hospitalisation de courte durée) en l’absence de médecin senior dans le service, lequel après un massage cardiaque, a été relayé par une équipe du servie de réanimation où la patiente était dirigée.

Le 12 février 2003, à 18h20, la patiente décédait sans avoir repris connaissance dans le service de réanimation du centre hospitalier Saint-Roch de Nice. Le rapport d’expertise a conclu que le décès était du à des « complications d’une anoxie cérébrale consécutive à un arrêt cardio-circulatoire consécutif à un hémopneumothorax bilatéral entraînant une hémorragie importante associée à une compression médiastinale ».

A la suite de ce décès, le Directeur général du CHU de Nice a saisi la DDASS des Alpes-Maritimes laquelle a diligenté une inspection à la suite de laquelle un rapport a relevé les dysfonctionnements suivants :

  • tri par une infirmière,
  • absence de prise en charge rapide par un médecin senior,
  • absence du chef de service non remplacé dans ses fonctions administratives : pour la désignation éventuelle d’un saignoir en chirurgie en remplacement rapide d’une personne malade.

Par ordonnance en date du 15 décembre 2004, un juge d’instruction du Tribunal de Grande Instance de Nice a renvoyé les différentes personnes physiques concernées ainsi que le Centre hospitalier universitaire de Nice, en tant que personne morale, pour homicide involontaire.

Par jugement du 29 mai 2006, le Tribunal correctionnel de Nice a :

  • relaxé le Docteur BE, agissant comme médecin pompier,
  • relaxé l’infirmière d’accueil et d’orientation,
  • relaxé le Docteur TO, faisant fonction d’interne,
  • relaxé le Docteur BA, interne,
  • soumis comme préalable à la déclaration de culpabilité du CHU de Nice, personne morale, la condamnation de personnes physiques agissant pour son compte, comme organe ou représentant.

Appel du jugement a été interjeté devant la 7ème Chambre A – Chambre correctionnelle de la Cour d’appel d’Aix-en-Provence, laquelle a, au terme de son arrêt, confirmé le jugement, sauf en ce qui concerne l’interne qui a été condamné à 4 mois d’emprisonnement avec sursis simple, et a retenu la responsabilité pénale du CHU de Nice et a infligé à ce dernier une amende de 20.000 euros, aux motifs suivants :

« Attendu que l’enquête et les débats ont révélé une défaillance manifeste du service de l’accueil de l’hôpital Saint Roch qui relève du CHU de Nice,

que cette défaillance consiste dans l’absence de médecin senior dans ce service alors que le titulaire était autorisé à s’absenter par son supérieur hiérarchique le Dr DE[…] responsable de toutes les unités des services des urgences, et ce en infraction au réglement intérieur qui impose la seniorisation de chaque unité sectorisée de ces services, ainsi que l’accueil par un médecin seniorde chaque patient à charge pour lui, éventuellement, sous sa responsabilité d’attribuer le suivi de ce patient à un interne ou faisant fonction, et non comme semblait être à l’époque la pratique énoncée par le Dr DE[…] selon laquelle le médecin senior ne se déplaçait que sur demande du service ;

que cette désorganisation fautive n’a pas permis de prendre, dès l’arrivée de Madame F., les mesures appropriées qu’un médecin senior aurait dû mettre en oeuvre mais surtut dès le retour de cette patiente du service des radiographies puisque c’est à ce moment là que le processus vital s’est enclenché pour défaut de mise en place d’un protocole adéquat qui aurait permis d’éviter l’arrêt cardio circulatoire alors que l’existence de la pathologie majeure était révélée,

que cette faute patente est la cause indirecte et certaine du décès de Mme F., »

Saisie d’un pourvoi par le CHU de Nice, la Chambre criminelle de la Cour de cassation ((Cass. Crim., 9 mars 2010, Centre hospitalier universitaire de Nice, n°09-80.543, AJDA 2010, p. 1287.)) a en tous points confirmé la solution de la cour d’appel et déclaré le CHU coupable d’homicide involontaire, aux motifs suivants :

« Attendu que, pour infirmer ce jugement et déclarer le CHU coupable, l’arrêt retient que Valérie F. n’a pu, en raison du départ du médecin senior de la zone de chirurgie autorisé par le chef de service, être examinée par un médecin senior tant lors de son arrivée au service des urgences qu’à son retour du service de radiologie, alors que le pronostic vital était engagé ;  que la cour d’appel ajoute que cette défaillance manifeste du service d’accueil des urgences, en infraction au règlement intérieur de l’hôpital qui impose la présence d’un médecin senior dans chaque unité fonctionnelle de ce service, entretient un lien de causalité certain avec le décès de la victime ; »

Plusieurs points de droit mériteraient assurément d’être développés, tels que la responsabilité pénale des personnes morales et en particulier des centres hospitaliers, universitaires ou non, celle des internes et faisant fonction d’interne, etc., sans parler des nombreuses barrières qui n’ont pas fonctionné (en matière de gestion des risques), autrement dit les dysfonctionnements successifs observés au sein du service des urgences, mais le point juridique qui retient mon attention réside surtout dans la sanction pénale de l’inobservation d’un réglement intérieur propre au service des urgences.

On rapellera succinctement que ce réglement intérieur repose en l’espèce sur 4 principes essentiels : seniorisation, sectorisation, coordination et évaluation. La seniorisation s’appuie sur le principe de permanence des soins, prévu à l’article D.712-54 du code de la santé publique, dans sa rédaction en vigueur à la date des faits, lequel disposait : « l’équipe médicale doit être suffisante pour qu’au moins un médecin soit présent 24 heures sur 24 tous les jours de l’année, et assure l’examen de tout patient à l’arrivée de celui-ci dans le service. »

La permanence des soins est naturellement réaffirmée dans la version actuelle du code de la santé publique à l’article R.6123-18 et surtout à l’article D.6124-3.

On se bornera à conclure que s’il est permis de douter de la normativité d’un réglement intérieur propre à un service des urgences, force est toutefois de constater que c’est non le défaut de permanence des soins qui a été sanctionné mais le défaut de seniorisation, principe issu de la pratique.

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