(英文)おりど病院身体拘束裁判で身体拘束は違法と判決が出ました。皆様の手で日本の現状を世界に発信してください。

2023.2

Judgment of Nisshin City Oriodo Hospital Physical Restraint Trial (provisional title)

On January 20, the Nagoya District Court ruled in a trial in which the bereaved family sought damages from the hospital on the grounds that physical restraints were the reason their mother (91 years old) died of worsening pneumonia at the hospital.

Although the presiding judge, Naoyuki Iwai, denied any causal connection to the death, he recognized the illegality of the physical restraints and ordered the medical corporation operating "Nisshin OridoHospital" (Nisshin City, Aichi Prefecture) to pay one million yen in compensation money. Since neither the plaintiff nor the defendant appealed by the deadline, this judgment became final on February 8.

Physical restraints are prohibited by law in nursing homes, but there are no such regulations in general hospitals. In order to avoid the risk of falls and tumbling or pulling out intravenous tubes, restraints such as belts and straps are often used on patients with dementia or delirium (a condition that causes disorientation, loss of attention and thinking, and loss of awareness of time and place due to medication, illness, environmental changes, etc.).

In this latest court decision, it was recognized that even medical institutions are not allowed to easily detain patients. Let's take a look at the specific problems with the hospital's handling of the case.

In May 2017, Mrs. Shizuka (pseudonym) was admitted to a university hospital in Aichi Prefecture for treatment of pneumonia and her pneumonia symptoms improved with the administration of antibiotics. At the beginning of her hospitalization, she had difficulty moving from her bed, but with rehabilitation, she recovered to the point where she could transfer to a wheelchair with assistance and walk short distances using a walker.

However, when she ate, she developed a fever, which led to suspicion of aspiration pneumonia, and she was placed on a fasting diet and treated with intravenous antibiotics. In July of the same year, she was transferred to Nisshin Oriodo Hospital for continued treatment and rehabilitation. At that time, Mrs. Shizuka was able to stand up from her wheelchair and move to her bed by herself under the watchful eye of her doctor and family.

However, after the family left the visit, the nurses read information only from the nursing information sheet (nursing summary) from the university hospital that they received in advance, which stated that the patient had delirium and had an intravenous drip removed. The nurses used the following physical restraints on her:

・Attached fences around the bed in three places (so-called three-point fences).

・Covered the fences with cloth covers.

・Installed a sensor mat under the bed that notifies the nurse station if the patient goes down to the floor.

・Tied both of Mrs. Shizuka’s hands to the bed railing with a cord.

In addition, the nurse call button was left hanging on the wall and was not able to be used.

On the evening of the same day, when the nurses saw that Mrs. Shizuka raised herself up in bed and lifted the bed rails, they rebounded her hands with a cord and tightened a wide belt (suppression belt) around her torso without checking up on Mrs. Shizuka, despite her lung function was deteriorating.

Mrs. Shizuka, who weighed only 26 kilograms (57.3 pounds) when she was admitted to the hospital, was tightly strapped with an adult-sized torso restraint band. This prevented her diaphragm, which is essential for breathing, from moving, and her respiratory function probably deteriorated further.

For many years, at Nisshin City Orido Hospital, the medical staff did not communicate with the patients or grasp their conditions if the patient has dementia or delirium, who are at high risk of falling. They used full-course physical restraints (and may still be doing this).

Mrs. Shizuka had been able to use a walker to defecate in the toilet before she was transferred to the hospital, but this physical restraint deprived her of her physical freedom and she was forced to defecate in a diaper. During her hospitalization, a physical therapist (PT) and other staff provided rehabilitation training for about 20 minutes a day, but her hands and torso were still restrained, and the PT only moved her unrestrained legs.

Physical restraints on hospitalized patients are permitted only when necessary and unavoidable, and only to the minimum extent possible. In light of these circumstances, Chief Judge Iwai of the Nagoya District Court based his ruling on the 2010 Supreme Court ruling that physical restraint of hospitalized patients is permissible only when it is necessary and unavoidable under the circumstances below:

• Imminence (whether there were imminent circumstances)

• Non-substitutability (whether there was no other appropriate method)

• Temporary (whether there was a minimum necessity)

The court determines whether or not the restraint was appropriate in light of these three requirements.

Among the most problematic were the restraints on the torso and hands.

Although the court acknowledged that there was an imminent risk of falling, it ruled that "there were other appropriate methods" for restraining the body.

Specifically, the court noted that, even in light of the hospital's nursing system at the time, bed release sensors (a device in which a special clip is attached to the collar of hospital wear and nurses are notified if they come off) could have been used, or the patient could have been temporarily moved to a room near the nurses' station to strengthen supervision.

Incidentally, the hospital had one nurse for every 10 patients, with 12 nurses on the day shift and three on the night shift. At that time, 39 beds were in operation at the ward, with three patients requiring special observation.

Mrs. Shizuka's behavior of lifting the fence was often observed at the university hospital before she was transferred, but mostly when she had the urge to urinate. This fact had been communicated to Nisshin Oriodo Hospital as well.

However, such information was not taken into consideration. Therefore, the court also found that the hospital did not repeatedly explain to the patient to call the nurse when she had the urge to urinate, or ask the patient why she was trying to remove the fence.

Not only did the medical staff at Nisshin OritoHospital not conduct a fall down/slip assessment before initiating restraints in the first place, but they also did not obtain permission from the physician (the physician confirmed the restraints in the electronic medical record the next day).

Although the hospital manual required observation of the patient's progress every two hours, the nurses only recorded that they checked to see if the restraints had been securely fitted, and there was no record of the patient's condition. There was no review or observation to lighten or release the restraints in accordance with the patient's condition.The trial judge determined that the restraints were "not even the temporary."

The hospital argued that the restraints on the hands were necessary to prevent the patient from self-extracting an IV, but the IV had not yet been administered when the nurse initiated the restraints. Therefore, it was pointed out that "it cannot be said that there was a high degree of imminent need”.

Furthermore, even after the IV started, there were methods such as placing the tube in a place out of the person's field of vision or wearing mittens, which are lighter means of restraint, but it was never done. The presiding judge dismissed the hospital's appeal, stating, "An unnecessary amount of restraining was continued until the death of the patient, and it was not the minimum necessary time limit."

Based on the above circumstances, Judge Iwai found that "the restraints on the torso and hands were not deemed necessary nor unavoidable, and were therefore illegal.

On the other hand, he found that restraints such as three-point fences, fence covers, and sensor mats were necessary to detect the patient's attempt to get out of bed.

This is the second case in Japan in which a court has ruled that physical restraints in a general hospital is illegal.

Immediately after being transferred to Nisshin OriodoHospital, Mrs. Shizuka was placed under unnecessary restraints. Her pneumonia worsened rapidly, and she died only six days and two hours after admission. The restraints were not lifted until Mrs. Shizuka's death.

This is the current situation of Japanese hospitals.

2023  4/12  朝日新聞紙16ページに記事が掲載されています。同日、朝日新聞デジタル(有料会員) に記事が掲載されました。