The family of a magistrate who died following an operation at Mater Dei Hospital has lost a medical negligence lawsuit, after a court ruled that his death resulted from a rare complication rather than negligence by the medical team.
Magistrate Joseph Cassar died on 2 May 2017 aged 70 after suffering extensive internal bleeding caused by a tear in an artery during a procedure intended to restore blood circulation to his left leg.
His widow, Mary Cassar, and their children, Marisa and Stephen Cassar, subsequently sued the Chief Medical Officer and the Superintendent of Mater Dei Hospital, alleging that medical negligence had caused his death.
However, Judge Rachel Montebello dismissed their compensation claim, finding that the medical team had followed accepted professional standards and could not reasonably have detected the fatal bleeding before Cassar's sudden deterioration.
'The operation was a success'
In their court application, the family recalled a particularly distressing incident in which a senior member of the medical team approached them, announcing that the operation had been successful, despite already knowing that Cassar had died.
The procedure had technically succeeded in reopening the blocked artery and restoring blood flow. However, a tear sustained during the intervention had caused internal bleeding, which was only identified during the post-mortem examination.
The family maintained that what was supposed to have been a relatively straightforward procedure had unexpectedly ended in death. The hospital authorities denied negligence, insisting that Cassar had received appropriate treatment and that his death resulted from a recognised risk associated with the intervention.
A successful procedure followed by a fatal complication
Joseph Cassar had been suffering from poor circulation in his left leg, which caused pain and made walking difficult. Medical investigations revealed a severely narrowed and blocked artery, prompting doctors to recommend an angioplasty involving the insertion of a stent to restore blood flow.
The procedure was carried out by consultant radiologist Kenneth Saliba, assisted by other medical professionals. Saliba initially attempted to access the blocked artery from the left side but severe calcification prevented the necessary instruments from advancing.
He therefore approached the blockage from the right side, using a longer route to reach the affected artery.
The intervention successfully reopened the blockage, with medical imaging confirming that blood was once again flowing through the artery.
Shortly after the procedure was completed, Cassar complained of feeling unwell and nauseous before losing consciousness. Medical personnel immediately began resuscitation.
Although he briefly regained consciousness and was able to speak, his heart rhythm subsequently deteriorated and he died at approximately 1:35pm.
A post-mortem examination revealed a tear measuring approximately two centimetres in his left femoral artery, together with extensive internal bleeding in the pelvic region.
The family argued that medical personnel should have detected the tear and resulting haemorrhage earlier, potentially allowing doctors to intervene before his condition became critical.
Court finds bleeding could not reasonably have been detected
Judge Montebello found that Cassar's blood pressure, pulse and oxygen levels had been continuously monitored throughout the procedure and had remained stable. Nurses testified that he was conscious and speaking during the intervention, with one recalling that he was still joking with members of the medical team shortly before his condition deteriorated.
The court also examined the final angiogram, an imaging test performed before the procedure ended, which confirmed that the artery had reopened successfully without showing any signs of bleeding.
Medical evidence established that internal bleeding can initially go undetected because the body compensates for blood loss, with vital signs deteriorating rapidly only when the bleeding becomes extensive.
The judge concluded that the failure to identify the haemorrhage before Cassar collapsed did not, in itself, establish negligence.
The court also rejected allegations that Saliba had acted negligently by leaving the operating suite, noting that Cassar's vital signs were stable and other medical professionals remained present.
Medical experts confirmed that resuscitation began promptly and that accepted emergency procedures were followed.
Cassar had also signed a consent form after being informed of the risks associated with the procedure. An information leaflet provided to him specifically warned of the rare possibility of fatal bleeding.
Pre-existing heart condition contributed to death
The court also examined Cassar's medical history, including his longstanding smoking habit and pre-existing ischaemic heart disease.
Although the arterial rupture and resulting blood loss were the principal causes of his fatal collapse, the judge found that his underlying heart condition had also contributed.
The family argued that further cardiac screening should have been carried out before the procedure. However, the court accepted expert evidence that additional cardiac tests had not been shown to improve outcomes in comparable circumstances.
Family's compensation claim dismissed
The judge stressed that an unsuccessful medical outcome does not automatically establish negligence, particularly where doctors have followed accepted medical standards.
Although the procedure ended tragically, the evidence did not establish that Cassar's death resulted from negligence, incompetence or a failure to follow appropriate medical practices.
The family was consequently ordered to bear the legal costs of the proceedings.
Lawyer Rodianne Sciberras represented Cassar's family, while lawyers Andrew Grima and Sheldon Micallef appeared for the health authorities.
Judge Rachel Montebello presided over the First Hall Civil Court.