COLPA OMISSIVA DEL MEDICO, MORTE DEL PAZIENTE E NECESSITA’ DEL GIUDIZIO CONTROFATTUALE SECONDO LA CELEBERRIMA SENTENZA FRANZESE
La Corte Suprema – Cass. pen. Sez. IV, (ud. 10-05-2012) 28-05-2012, n. 20650 – cassa, ai soli effetti civili, essendosi nelle more prescritto il reato contestato, la sentenza di condanna di un medico di pronto soccorso e di un internista per la morte di un paziente conseguente ad infarto acuto.
Il giudice a quo in riforma della sentenza assolutoria di primo grado aveva ritenuto la responsabilità omissiva dei due imputati, attribuendogli il decesso per colpa generica, per avere omesso di richiedere una consulenza cardiologica e di effettuare i necessari accertamenti diagnostici (in particolare il dosaggio degli enzimi cardiaci) nonostante il paziente presentasse un dolore toracico intermittente, che rappresenta il sintomo principale e più frequente dell’insorgenza di un infarto.
In conseguenza di tali omissioni formulavano una errata diagnosi di patologia di origine gastrica con dimissioni del malcapitato che decedeva nella propria abitazione a distanza di dodici ore laddove, se si fosse pervenuto alla corretta diagnosi di angina ingravescente, si sarebbe consentito di instaurare con la dovuta urgenza la terapia del caso.
Hanno in ogni caso errato gli imputati, secondo la motivazione della sentenza di appello, per non aver trattenuto il paziente in osservazione in ospedale, pur avendo comunque sospettato la sussistenza della patologia cardiaca, così impedendogli di trovarsi al momento della crisi cardiaca rivelatasi letale in una struttura idonea ed a ricevere, di conseguenza, le cure necessarie ad impedire l’evento mortale.
La Corte di Cassazione censura siffatta sentenza per non spiegare la ritenuta sussistenza del nesso di causalità tra le plurime omissioni contestate e l’evento letale e per non avere operato, in particolare, il c.d. giudizio controfattuale al fine di stabilire se, in concreto, le condotte omesse, se ipotizzate effettivamente poste in essere, sarebbero state idonee ad evitare l’evento od a ritardarne significativamente la sopravvenienza.
Trattasi dell’ennesima applicazione del principio di diritto fissato nella celeberrima sentenza Franzese (SS.UU.,sentenza 11.9.2002, n. 20328) secondo il quale in ambito medico-chirurgico il nesso di causalità per il reato omissivo improprio deve ravvisarsi solo quando alla stregua di un giudizio controfattuale condotto in base ad una generalizzata regola di esperienza o di una legge scientifico-universale o statistica, si accerti che ipotizzando come sussistente in concreto la condotta omessa l’evento non si sarebbe verificato o si sarebbe verificato in epoca significativamente posteriore o con minore intensità lesiva.
Nel caso deciso, invece, la sentenza cassata si era limitata in via del tutto apodittica ed apparente ad affermare che se il paziente fosse rimasto in ospedale avrebbe potuto ricevere tutte le cure e salvarsi, senza in alcun modo accertare se concretamente, considerando tutti i dati disponibili, in base ad una generalizzata regola di esperienza o ad una legge scientifico-universale o statistica, la permanenza nel nosocomio avrebbe con ragionevole certezza impedito la morte.
Cass. pen. Sez. IV, (ud. 10-05-2012) 28-05-2012, n. 20650
REPUBBLICA ITALIANA
IN NOME DEL POPOLO ITALIANO
LA CORTE SUPREMA DI CASSAZIONE
SEZIONE QUARTA PENALE
Composta dagli Ill.mi Sigg.ri Magistrati:
Dott. MARZANO Francesco – Presidente
Dott. FOTI Giacomo – Consigliere
Dott. MASSAFRA Umberto – Consigliere
Dott. PICCIALLI Patrizia – Consigliere
Dott. VITELLI CASELLA Luca – rel. Consigliere
ha pronunciato la seguente:
sentenza
sul ricorso proposto da:
1) L.C. N. IL (OMISSIS);
2) F.E. N. IL (OMISSIS);
avverso la sentenza n. 461/2009 CORTE APPELLO di ROMA, del 10/12/2010;
visti gli atti, la sentenza e il ricorso;
udita in PUBBLICA UDIENZA del 10/05/2012 la relazione fatta dal Consigliere Dott. LUCA VITELLI CASELLA;
Udito il Procuratore Generale in persona del Dott. Vito D’Ambrosio, che ha concluso per il rigetto dei ricorsi;
Udito, per la parte civile, l’avv. Giovanni Cametti del foro di Latina che ha concluso per il rigetto dei ricorsi;
Udito il difensore Avv. Mario Pellegrino del foro di Latina che insiste per l’accoglimento del ricorso.
Svolgimento del processo
Con sentenza emessa in data 10 dicembre 2010, la Corte d’appello di Roma, in riforma della sentenza 18 giugno 2008 del Tribunale di Latina – Sezione di Terracina, in accoglimento delle impugnazioni proposte dal Procuratore della Repubblica presso il Tribunale di Latina e dalle parti civili, dichiarava non doversi procedere nei confronti di F.E. e di L.C. in ordine al delitto di cui all’art. 589 cod. pen. commesso in data (OMISSIS) in (OMISSIS) in danno di S.B., perchè estinto per maturata prescrizione; condannava gli imputati al risarcimento dei danni in favore delle costituite parti civili, da liquidarsi in separata sede.
Ad entrambi i prevenuti si imputava di aver cagionato, per colpa generica, la morte di S.B., avendo essi omesso,in qualità di medici in servizio all’Ospedale di (OMISSIS): il L., in veste di medico di turno al pronto soccorso; la F., nella qualità di internista, di richiedere una consulenza cardiologica e di effettuare i necessari accertamenti diagnostici (quali il dosaggio degli enzimi cardiaci), a fronte della sintomatologia riscontrata nel paziente: dolore toracico intermittente. Di guisa che, in difetto della corretta diagnosi di angina ingravescente che avrebbe consentito di instaurare con urgenza la necessaria terapia, il paziente veniva dimesso con l’errata diagnosi di patologia di origine gastrica. Sopravveniva quindi, a distanza di alcune ore, il decesso per arresto cardiocircolatorio in paziente portatore di in infarto acuto.
La Corte distrettuale, contrariamente a quanto asserito dal Primo Giudice, ha messo in luce i profili di colpa per negligenza e per imperizia connotanti le omissioni contestate agli imputati, colposamente correlate alla produzione dell’evento mortale, sopravvenuto per infarto acuto a poche ore dalle dimissioni del paziente dall’Ospedale di (OMISSIS) ove il paziente si era recato nella mattinata del (OMISSIS) lamentando un dolore toracico che rappresenta il sintomo principale e più frequente dell’insorgenza della patologia cardiaca. Hanno ritenuto i Giudici d’appello che una siffatta diagnosi avrebbero potuto gli stessi medici immediatamente e correttamente formulare con l’esecuzione degli esami ematochimici relativi agli enzimi cardiaci (la cui modificazione, dopo sei ore dall’esordio del dolore risalente, nel caso di specie, a quattro giorni prima, avrebbe confermato la necrosi del tessuto cellulare cardiaco, mediante il test dell’enzima CPK – MB) a tanto non essendo sufficiente, com’ è noto, la mera registrazione dell’elettrocardiogramma. In ogni caso – ha altresì osservato la Corte d’appello – i prevenuti, che avevano comunque sospettato la sussistenza di patologia cardiaca, erano tenuti a trattenere il paziente in ospedale in osservazione, anche in caso di omessa esecuzione dei suddetti esami ematochimici di guisa che costui,colto ad ore 22,00, dalla crisi cardiaca (poi rivelatasi fatale) mentre si trovava nella propria abitazione, avrebbe potuto ricevere, in struttura idonea, tutte le cure necessarie,ex se idonee ad evitare l’evento mortale.
Propongono gli imputati, per tramite del difensore, ricorsi cumulativi per cassazione, deducendo due motivi per violazione di legge e per mancanza, contraddittorietà od illogicità della motivazione in punto alla responsabilità, che possono così sintetizzarsi.
Sostengono i ricorrenti che, in difetto di esame autoptico atto a dimostrare se, al momento della visita eseguita sul paziente nella mattinata del (OMISSIS), fosse in atto una patologia cardiaca – peraltro ragionevolmente da escludere in base ai risultati normali di due elettrocardiogrammi, eseguiti a due ore di distanza l’uno dall’altro ed in assenza di chiari elementi obiettivi emersi dalla visita clinica e dalla valenza equivoca della natura e della localizzazione del dolore riferito dal paziente – non avrebbe potuto la Corte distrettuale, nel far luogo alla riforma della sentenza di assoluzione di primo grado, ritenere la sussistenza sia del nesso di causalità – previa corretta formulazione del giudizio c.d. controfattuale – tra l’evento mortale (sopravvenuto dopo ben dodici ore dall’avvenuta dimissione del paziente) e le omissioni colpose ascritte agli imputati sia di queste ultime, fondando il proprio convincimento esclusivamente su di un giudizio ex post, per esser il paziente deceduto per arresto cardio – circolatorio,dodici ore dopo le dimissioni dall’ospedale. Inoltre, secondo gli imputati, i Giudici d’appello avrebbero del tutto omesso di motivare in ordine al dato emerso dall’esame dibattimentale dei diversi consulenti tecnici medico – legali che concordemente hanno messo in discussione l’effettiva idoneità dei dosaggi degli enzimi cardiaci agli effetti della diagnosi precoce dell’angina ingravescente che presuppone una patologia infartuale in atto, invece esclusa, nel caso di specie, dagli accertamenti strumentali e clinici eseguiti dagli imputati sul paziente. Né avrebbero considerato le deposizioni testimoniali delle due infermiere che ebbero ad assistere ciascuno degli imputati all’atto di raccogliere l’anamnesi dal paziente il quale ebbe a riferire ai medici di soffrire da tempo di patologia gastrica e non cardiaca.
Concludono per l’annullamento della impugnata sentenza e mandare assolti gli imputati nel merito.
Motivi della decisione
Il ricorso deve esser rigettato a fini penali perchè infondato, non sussistendo le condizioni di legge per la sussumibilità del caso nella previsione dell’art. 129 cod. proc. pen., comma 2, come invocato dal difensore di entrambi gli imputati. Il sindacato di legittimità ai fini dell’eventuale applicazione dell’art. 129 cod. proc. pen., comma 2, resta invero circoscritto all’accertamento della ricorrenza delle condizioni per addivenire ad una pronuncia di proscioglimento nel merito con una delle formule prescritte: la conclusione può essere favorevole al giudicabile solo se la prova dell’insussistenza del fatto o dell’estraneità ad esso dell’imputato risulti, ictu oculi, evidente sulla base degli stessi elementi e delle medesime considerazioni posti a fondamento della sentenza impugnata (all’esito di un approccio valutativo da ricondurre più al concetto della “constatazione” che a quello dell’”apprezzamento”: cfr. S.U. n. 35490/2009) senza possibilità di nuove indagini ed ulteriori accertamenti che sarebbero incompatibili con l’operatività della causa estintiva, già dichiarata, nel caso di specie, dalla Corte distrettuale. Qualora il contenuto complessivo della sentenza non prospetti, nei limiti e con i caratteri richiesti dall’art. 129 cpv. cod. proc. pen., l’esistenza di una causa di non punibilità più favorevole all’imputato, prevale l’esigenza della definizione immediata del processo, a seguito della sopravvenienza dell’estinzione del reato per maturata prescrizione. Secondo il consolidato orientamento della giurisprudenza di legittimità, nel caso in cui già risulti una causa di estinzione del reato, financo la sussistenza di una nullità (pur se di ordine generale) non è rilevabile nel giudizio di cassazione, “in quanto l’inevitabile rinvio ai giudice di merito è incompatibile con il principio dell’immediata applicabilità della causa estintiva” (in tal senso, ex piurimis: S. U. n. 1021/2001; S. U. n. 35490/2009).
Come pure è precluso alla Corte di Cassazione un riesame dei fatti, agli effetti penali, finalizzato ad un eventuale annullamento con rinvio della decisione per vizi attinenti alla sua motivazione (sia con riferimento alle valutazioni del compendio probatorio, sia con riferimento al vaglio delle altre deduzioni).
Nella concreta fattispecie, nella sentenza della Corte distrettuale non sono riscontrabili elementi di giudizio idonei ad integrare la prova evidente dell’innocenza dei ricorrenti in presenza della causa estintiva del reato già dichiarata (la prescrizione),ma risultano, anzi, enunciate valutazioni di segno diametralmente opposto, logicamente conducenti all’accertamento della responsabilità dei prevenuti stessi, con precipuo riferimento ai profili di colpa generica, ascrivibili, per negligenza, imprudenza ed imperizia professionali agli stessi medici che ebbero ad occuparsi del caso di S.B.. E’ sufficiente in questa sede richiamare integralmente il percorso motivazionale seguito dal Giudice di secondo grado, come sintetizzato in narrativa (onde evitare superflue ripetizioni) pur non sfuggendo l’inadeguatezza dell’apparato argomentativo relativamente al tema del nesso eziologico come più diffusamente si avrà modo di dire in prosieguo, esaminando il ricorso cumulativamente proposto, anche ai fini civili.
Ed invero la declaratoria di estinzione del reato per intervenuta prescrizione comporta, ex art. 578 cod. proc. pen. l’obbligo di esaminare compiutamente i motivi di impugnazione, e, di conseguenza, anche il materiale probatorio acquisito, ai soli effetti delle disposizioni e dei capi della sentenza che concernono gli interessi civili (in tal senso, ex plurimis, S.U. n. 35490/2009, Tettamanti).
Né può giungersi alla conferma della condanna, anche solo generica, al risarcimento del danno (sancita dalla Corte d’appello) in ragione della mancanza di prova dell’innocenza dell’imputato, alla stregua di quanto previsto dall’art. 129 cod. proc. pen., comma 2. Le censure dedotte con il ricorso proposto nell’interesse degli imputati L. e F. assumono certamente rilievo per quel che riguarda le statuizioni della Corte d’Appello concernenti gli effetti civili, ai sensi dell’art. 574 cod. proc., comma 4 e si presentano, al riguardo, fondate per le ragioni di seguito indicate. I Giudici di seconda istanza hanno invero sufficientemente delineato, pervenendo alla riforma della pronunzia assolutoria del tribunale, i profili di colpa generica, contestati agli imputati nel capo d’accusa e riferiti alla negligenza, alla imprudenza ed imperizia professionali che indussero entrambi ad omettere una tempestiva diagnosi di angina ingravescente (foriera delle complicanze infartuali poi sopravvenute), condizionata alla previa esecuzione in loco o previo trasferimento del paziente in altro nosocomio attrezzato, degli esami ematochimici relativi agli enzimi cardiaci. Poiché la comparsa dei primi dolori toracici “intermittenti” avvertiti dal paziente risaliva a quattro giorni prima e poiché la modificazione degli enzimi cardiaci (ed in particolare dell’enzima CPK – MB specificamente mirato a comprovare la necrosi del tessuto cellulare cardiaco) sopravviene dopo non meno di sei ore dall’esordio del dolore, l’effettuazione del dosaggio sarebbe valso a rivelare una patologia cardiaca silente al momento della visita a differenza dell’esame strumentale tramite l’elettrocardiogramma,idoneo a fini diagnostici solamente in caso di patologia conclamata ed in atto. Un siffatto approfondimento diagnostico, anche a voler ipotizzare l’equivocità della localizzazione e delle connotazioni specifiche del dolore toracico avvertito dal paziente ad intermittenza, qualora avesse condotto ad escludere ogni modificazione enzimatica, si sarebbe comunque rivelato idoneo a sciogliere ogni sospetto o dubbio (evidentemente insorto nella mente degli imputati, come dimostrato dalla prescrizione all’atto delle dimissioni dei paziente, di eseguire un elettrocardiogramma, in caso di ricomparsa del dolore toracico) sulla origine cardiaca della patologia de qua.
Avevano quindi pacificamente omesso gli imputati, per imprudenza e per negligenza, di trattenere in osservazione il paziente.
La Corte d’appello, data contezza del proprio convincimento in ordine alla sussistenza della colpa dei prevenuti, ha invece, come lamentato dai ricorrenti, sostanzialmente obliterato di spiegare le ragioni poste alla base della pur ritenuta sussistenza del nesso di causa tra le plurime omissioni risalenti agli imputati e l’evento, omettendo di far ricorso, in caso di reato omissivo improprio, al c.d. giudizio controfattuale al fine di stabilire se l’azione o le condotte positive ritenute doverose ed invece omesse, nel caso concreto, ove ipotizzate come poste in essere dagli imputati, sarebbero state idonee ad evitare l’evento od a ritardarne significativamente la sopravvenienza. Richiamando e riaffermando quindi l’insegnamento delle Sezioni Unite (cfr. n. 30328 del 2002, Franzese) va detto che la verifica dell’esistenza del nesso di causalità tra la condotta omissiva del sanitario e l’evento lesivo deve in concreto operarsi, in termini di ragionevole certezza (“alto o elevato grado di credibilità razionale” o “probabilità logica”), secondo tutte le circostanze che connotano il caso, e non già in termini di mera probabilità statistica pur rivelatrice di “serie ed apprezzabili probabilità di successo” per l’azione impeditiva dell’evento. Al contrario, con argomentazioni sostanzialmente apodittiche e meramente apparenti, la Corte distrettuale si è limitata sul punto unicamente ad affermare (fgl. 8) che “è assolutamente evidente che se il paziente fosse rimasto in ospedale, anche nell’ipotesi in cui non fossero stati effettuati gli esami ematochimici – che però erano doverosi – egli al momento della crisi insorta intorno alle ore 22, avrebbe potuto ricevere tutte le cure necessarie e salvarsi”. Si impone quindi un approfondito riesame su tale connotato fondamentale agli effetti del riconoscimento della responsabilità degli imputati, sia pure ai soli effetti civili, cui dovrà procedere il giudice civile di rinvio.
Appare opportuno ancora sottolineare che, in presenza della parte civile e di conseguenti statuizioni agli effetti civili (come nel caso di specie) una volta pronunciata dal giudice di appello declaratoria di estinzione del reato per prescrizione, pur all’esito dell’imprescindibile esame del compendio probatorio, come è avvenuto nella concreta fattispecie, eventuali vizi motivazionali non possono che rilevare ai soli effetti civili, dovendo la vicenda penale considerarsi ormai definitivamente conclusa con la declaratoria di estinzione del reato (fatta salva, ovviamente, l’evidenza della prova dell’innocenza: evidenza, di certo non rilevabile nel caso in esame): e ciò, perchè – come chiarito da questa Suprema Corte (S.U. n. 35490/2009) e come sopra già evidenziato – il rinvio del procedimento al nuovo esame del giudice del merito (sul versante penale) risulta del tutto incompatibile con l’obbligo di immediata declaratoria della causa di estinzione del reato. Conclusivamente, la sentenza impugnata va annullata ai fini civili, con rinvio al giudice civile competente per valore in grado di appello ex art. 622 cod. proc. pen., che provvederà anche al regolamento delle spese tra le parti, del presente giudizio.
P.Q.M.
Annulla la sentenza impugnata agli effetti civili con rinvio al giudice civile competente per valore in grado d’appello cui rimette anche la decisione sul regolamento delle spese anche del presente giudizio. Rigetta il ricorso nel resto, a fini penali.
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