Judgment No. 95/2023/HS-ST: Violation of Regulations on Medical Examination and Treatment Causing Death

Judgment No.: 95/2023/HS-ST

Defendant: Dr. Phan Đức H

Victim: Nguyễn Thị Lệ T (Deceased)

Legal Representatives of the Victim: Bà Từ Thị Đúng and Nguyễn Văn Ái

Criminal matter: Violation of regulations on medical examination and treatment causing death


Case summary

Dr. Phan Đức H (hereinafter Dr. H) is the holder of a master’s degree and medical doctor, who was granted medical practice certificate number: 0000916/ĐNO-CCHN issued by the Department of Health of Đắk Nông Province on 01/08/2014. The details state, “Professional Qualification: Specialized Doctor in Cosmetic Surgery” and “Scope of Professional Activity: Examination and Cosmetic Surgery.” Dr. Phan Đức H resided at house number XYZ, M L Street, B H H A Ward, B T District, which was not licensed to operate as a Cosmetic Surgery Clinic. However, Dr. H purchased medical supplies and equipment to practice cosmetic surgery at this location.

On 03/07/2021, Ms. Nguyễn Thị Lệ T (hereafter Ms. T) came to Dr. Phan Đức H’s house at number XYZ, M L Street, B H H A Ward, B T District to undergo cosmetic surgery on her breasts and vagina. The surgery cost was 47,000,000 VND and Ms. T paid an advance of 12,000,000 VND. Prior to the procedure, Dr. H gave Ms. T 02 Seduxen pills and 01 Clopheramine pill as well as administered an intravenous drip and measured her blood pressure and heart rate. Then, Dr. H brought Ms. T into the operating room. Dr. H proceeded to inject 02 ampoules of Lidocaine 2% 2ml under the skin of Ms. T’s breasts. About 10 minutes later, Dr. H used a scalpel to cut the skin under the right breast, causing Ms. T to cry out in pain. Dr. H then injected more Lidocaine mixed with 01 drops of Adrenaline (equivalent to 0.01ml) as a booster. By the time the right breast cavity was opened, Dr. H had injected approximately 10 ampoules of anesthesia. When Dr. H continued to open the left breast cavity with the scalpel, Ms. T showed signs of respiratory failure, and facial cyanosis, with her pulse and blood pressure shown on the electronic monitor at 70/40. Dr. H suspected Ms. T was experiencing a drug reaction, stopped the surgery, and provided intensive resuscitation support with oxygen. However, Ms. T began to have seizures and increased phlegm secretion. Dr. H used a suction machine, inserted an endotracheal tube, manually ventilated her, and administered 02 saline bottles. Dr. H also injected 01 ampoules of Adrenaline into the saline line and directly injected 02 ampoules of Adrenaline into Ms. T’s heart area. By 15:00 the same day, Ms. T passed away. Subsequently, Dr. H contacted Ms. T’s mother to inform her to pay the hospital fees, but when her family called back, Dr. H did not answer. Upon ascertaining that Ms. T was from Trà Vinh Province, Dr. H borrowed a car from his son Phan Đức H1 (plate number 51H-814.03) and personally drove the car, transporting Ms. T’s body to Trà Vinh Province to hand it over to her family for burial. When Dr. H’s car arrived in Trà Vinh Province, he was unable to contact Ms. T’s family and feared the corpse would decompose. As such, Dr. H took Ms. T’s body to Hai Viên Coffin House in Giồng Dầu Hamlet, Hòa Ân Commune, Cầu Kè District, Trà Vinh Province. Dr. H informed this business that if her family could not be found within 02 hours, they should arrange the burial and keep Ms. T’s body. Hearing this, Mr. Lưu Hữu D, the owner of the Coffin House, became suspicious and reported the incident to the Cầu Kè District Police, Trà Vinh Province. At around 09:00 on 05/07/2021, after Dr. H returned home, the Cầu Kè District Police Investigation Agency, Trà Vinh Province, opened the matter and subsequently informed the Bình Tân District Police Investigation Agency to handle the case according to its jurisdiction.


Forensic Examination Report on Histopathology No: 54/21/MBH, dated 12/7/2021, and Forensic Examination Report on Toxicology No: 263/266/337/21/ĐC, dated 15/7/2021 by the National Institute of Forensic Medicine, Southern Branch in Ho Chi Minh City. Conclusion: Ms. Nguyễn Thị Lệ T had organ congestion. The renal tubules were filled with red blood cell casts. The interstitial muscle was swollen, with hemorrhage in the fatty connective tissue. There was acute myocardial malnutrition. Pulmonary congestion and acute pulmonary edema were present. Some cells in the organs were in the necrosis stage. Lidocaine was found in the samples of Ms. Nguyễn Thị Lệ T’s organs. No other toxic substances were found.

Forensic Autopsy Report No: 426/KLGĐ, dated 16/7/2021 by the Criminal Technical Department of the Trà Vinh Provincial Police, concluded: that Ms. Nguyễn Thị Lệ T’s entire body was bloated and necrotic in many places. The skin and muscle under both breasts were torn, with bruises around the tear. There was bruising under the skin and muscle under the right breast, and the skin and muscle were separated from the ribs and sternum. Both lungs were congested, swollen, and hemorrhagic; the bronchial system showed increased secretion, congestion, and hemorrhage. The heart muscle was flabby, and the posterior surfaces of both ventricles were congested and hemorrhagic. The heart chambers contained a small amount of unclotted blood. There was acute myocardial malnutrition, acute pulmonary congestion and edema, and congestion and necrosis in other organs. Lidocaine was found in the samples of internal organs. The main cause of Ms. Nguyễn Thị Lệ T’s death was acute heart failure and acute respiratory failure in the context of Lidocaine presence.


Official Dispatch No: 1060/TTra, dated 21/10/2021 from the Inspectorate – Ho Chi Minh City Department of Health and Official Dispatch No: 133/SYT-NVD, dated 13/10/2021 from the Pharmaceutical Department of the Ho Chi Minh City Department of Health regarding the response to the uses of the confiscated drugs and the breast augmentation cosmetic surgery procedure as follows: Chlorphenamine is an antihistamine, used to treat symptoms of seasonal and perennial allergic rhinitis, urticaria… or anaphylactic shock. Diazepam, commercial name Seduxen, is a sedative, anxiolytic, sleep-inducing drug used to treat states of anxiety, agitation, and insomnia. In cases of depression with accompanying anxiety, agitation, and insomnia, diazepam can be used with antidepressants or as a pre-anesthetic before surgery. Gentamicin is an aminoglycoside antibiotic, usually used in combination with other antibiotics to treat severe systemic bacterial infections. Midazolam, commercial name Paciflam, is a benzodiazepine sedative used for anesthesia. Lidocaine is a local anesthetic and a class 1B antiarrhythmic drug used for local mucosal anesthesia before examination, endoscopy, technical device placement, or other procedures, and to relieve pain symptoms for many diseases. Adrenaline is a sympathomimetic drug for anaphylactic reactions, supporting anesthesia, bronchodilation, anti-congestion, and vasoconstriction. Lignospan Standard is indicated for local anesthesia. Sodium chloride is an electrolyte-replenishing drug. Povidone iodine is an antiseptic for contaminated skin wounds and mucosa before surgery, or for washing medical instruments before sterilization.

Referral No: 300/PC-NVY, dated 18/10/2021 from the Medical Professional Department of the Ho Chi Minh City Department of Health in response to Official Dispatch No: 1021/Ttra from the Inspectorate Department. At number XYZ, Mã Lò Street, Bình Hưng Hòa A Ward, Bình Tân District, the Department of Health did not issue an operating license, technical procedure approval, or technical list approval for any medical examination and treatment facility. Dr. Phan Đức H has not been approved by the Department of Health to perform techniques related to cosmetic surgery at any medical examination and treatment facility in Ho Chi Minh City. The fact that Dr. Phan Đức H conducted medical examinations and treatments, and performed medical procedures at number XYZ, Mã Lò Street, Bình Hưng Hòa A Ward, Bình Tân District was illegal.


Official Dispatch No: 3098/BVĐHYD-KHĐT, dated 08/11/2021 from the University Medical Center Ho Chi Minh City. On 15/4/2011, the hospital issued certificate No. 12/GCN-BVĐHYD to Dr. Phan Đức H for attending the “Basic Cosmetic Liposuction” training class, and on 16/7/2011, issued certificate No. 24/GCN-BVĐHYD for attending the “Basic Cosmetic Breast Augmentation” training class. These certificates do not certify that the trainee is allowed to directly perform breast augmentation surgery.


Official Dispatch No: 50/TTra, dated 13/01/2022 from the Inspectorate of the Ho Chi Minh City Department of Health. There is no basis to determine whether the dose of Lidocaine used by Dr. Phan Đức H during the breast augmentation surgery for Ms. Nguyễn Thị Lệ T was an overdose. The use of anesthetics by Dr. Phan Đức H for performing “cosmetic breast and vaginal surgery” was not in accordance with regulations.


Official Dispatch No: 17/PC09, dated 02/3/2022 from the Criminal Technical Department of the Trà Vinh Provincial Police. The main cause leading to Ms. Nguyễn Thị Lệ T’s death was acute heart failure and acute respiratory failure likely caused by Lidocaine.


Defendant: Dr. Phan Đức H. The defendant holds key qualifications and certifications such as a Master’s Degree in Medicine, a Medical Practice Certificate with a specialization in “Specialist Doctor in Cosmetic Surgery” and “Scope of Professional Activity: Examination and Cosmetic Surgery,” along with various other certificates from training courses in aesthetics. During his time studying at the Cosmetic Surgery Department of Phú Nhuận District Hospital, the defendant met Ms. Nguyễn Thị Lệ T, who requested breast augmentation and vaginal surgery after childbirth. The defendant agreed and quoted her a price of 74,000,000 VND. Later, he reduced the price to 50,000,000 VND. After some time, the defendant further reduced the price by 3,000,000 VND, only charging her 47,000,000 VND, and scheduled the surgery date. As agreed, around 08:00 on 03/07/2021, Ms. T came alone to the defendant’s house and paid him an advance of 12,000,000 VND, with the remaining amount to be paid later. The process of conducting the surgery and the subsequent incident occurred as described in the case details. The Trà Vinh District Police investigated the incident and the defendant admitted to committing the crime as described in the indictment. The defendant voluntarily compensated 30,000,000 VND for Ms. T’s funeral expenses and 160,000,000 VND for emotional distress to Ms. T’s family. Additionally, he compensated 1,676,320,000 VND for the upbringing of Ms. T’s two children until they reached 18 years old.


Legal representatives of Ms. T: Mrs. Từ Thị Đúng and Nguyễn Văn Ái. The funeral cost of 30,000,000 VND has been fully paid by the victim’s family. They requested only a one-time compensation payment of 1,676,320,000 VND, which includes 617,760,000 VND for the upbringing of Ms. T’s two children and 898,560,000 VND calculated from the time of Ms. T’s death until the children reached 18 years old, and 160,000,000 VND for emotional distress. They also requested a lenient sentence for the defendant.


Indictment No: 03/CT-VKS, dated December 13, 2022, by the People’s Procuracy of Bình Tân District, Ho Chi Minh City, prosecuted Dr. Phan Đức H before the People’s Court of Bình Tân District, Ho Chi Minh City for “Violation of regulations on medical examination and treatment” under Point a, Clause 1, Article 315 of the 2015 Penal Code.


Representative of the People’s Procuracy of Bình Tân District: The defendant’s confession aligns with the documents and evidence in the case file as well as the indictment’s content. There is sufficient basis to confirm this is a case of “Violation of regulations on medical examination and treatment” committed by the defendant Dr. Phan Đức H while operating without a license and without authorization to perform cosmetic surgery in Ho Chi Minh City. This led to Ms. T’s death during surgery, followed by the defendant’s arrest. The defendant’s actions were dangerous to society, directly infringing on the State’s management regime of medical services and violating another person’s life, warranting a severe punishment. However, the defendant has provided a sincere confession, shown remorse, and has partially compensated the victim’s family to mitigate the consequences. Additionally, the defendant’s parents contributed to the revolution, so a lenient sentence should be considered.


Judgment of the Court

There is sufficient evidence to determine that the defendant Dr. Phan Đức H committed the crime of “Violation of regulations on medical examination and treatment.” The defendant’s criminal acts were serious, causing not only the loss of another person’s life but also diminishing the State’s effectiveness in managing medical services. The defendant was aware that his actions were wrong and illegal, but due to negligence, overconfidence, and disregard for the Medical Examination and Treatment Law, he caused a fatality. Therefore, the defendant must bear criminal responsibility with a severe and commensurate sentence corresponding to the nature and extent of the crime, as well as his personal circumstances, to adequately educate, deter, and prevent similar crimes in society.


Decision of the Court

The defendant Phan Đức H is found guilty of “Violation of regulations on medical examination and treatment.” The Court acknowledges the defendant’s voluntary compensation of 30,000,000 VND for funeral expenses and 1,676,320,000 VND for emotional distress and upbringing of the victim’s two children until they reach 18 years old. It is ordered that the evidence, including the drugs and medical equipment used for surgery at the unauthorized medical facility of the defendant Dr. Phan Đức H, be confiscated and destroyed.


Legal basis

Point A, Clause 1, Article 315; Points s, Clause 1, Clause 2, Article 51; Article 38 of the 2015 Penal Code; Clause 2, Article 48 of the 2015 Penal Code; Articles 357, 468, 585, 586, 591, 357 and 468 of the 2015 Civil Code.