Suspected fatal drug intoxication during resuscitation after submersion asphyxia: a case report

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INTRODUCTION

Fatal incidents in water occur under various circumstances, including common drowning cases and less frequent causes like injuries from electrogenic animals.¹

There are also frequent instances when, during or immediately following a water-related incident, the victim receives assistance (first aid, etc.) that is sometimes inadequate and could adversely affect the outcome [1].

Resuscitation efforts frequently lead to what is known as “postresuscitation disease,” with a substantial number of cases resulting in death. The trigger is global ischemia and hypoxia (absence of oxygen in the body or specific organs, tissues, or blood) followed by reperfusion and reoxygenation during successful resuscitation efforts [2]. According to Russian authors, after successful resuscitation, only 15%–20% of patients experience a rapid recovery of adequate consciousness levels, whereas the remaining 80% go through postresuscitation disease, which results from pathological processes that developed both during the cessation of circulation and after the effective restoration of cardiac activity [3]. A study by international researchers shows that fewer than 5% of patients who have undergone cardiopulmonary resuscitation fully recover after being discharged [4]. These details indicate a poor prognosis and underscore its nearly inevitable nature, even with the successful recovery of vital functions in a hospital setting. In this context, a detailed analysis of individual cases becomes crucial, allowing for the identification of issues in care and their expert assessment.

This study provides an analysis of a case where a child experienced asphyxiation in a swimming pool, resulting in death 16 days later in a medical facility. To achieve this, the following were examined:

• Video surveillance footage totaling 6 hours, 25 minutes, and 18 seconds
• Report on the autopsy of K.’s body
• Report on the commission’s forensic medical examination with the involvement of specialized experts, including an emergency doctor and a toxicologist
• Forensic histology report, and
• Anindependent forensic medicine andtoxicology expert’s report, along withother criminal case materials containing medical findings.

The study employed visual observation, modeling, analytical, and comparative legal methods. To organize and compare the data collected, Microsoft Excel® (Microsoft Office, USA) was used.

CASE DESCRIPTION

Details of the Incident

The current criminal case was initiated on June 27, 2022, by the inter-district investigative department of the Main Investigative Directorate of the Investigative Committee of the Russian Federation for Saint Petersburg, based on the elements of a crime under paragraph “b” part 2 of article 238 of the Criminal Code of the Russian Federation (CC RF)² Initially, the investigation assumed that on June 27, 2022 an unidentified employee of the aqua club “XXXX” provided services that did not meet safety requirements, allowing child K., born in 2018, to use the pool in violation of safety requirements, as a result of which on the specified day, between 14:13 and 17:46, drowning occurred in the fresh water of the specified pool, leading to:

• astate afterclinical death (circulatory arrest for >30)
• Glasgow Coma Scale score 3 (E 1, M 1, V 1)³
• pulmonary aspiration, and
• multiple organ dysfunction syndrome (acute cerebral insufficiency, acute respiratory failure, acute cardiovascular insufficiency, acute kidney injury).

Thus, services were provided that do not meet safety standards for consumers’ life and health.

Child K. died on July 12, 2022, at 08:13 in a pediatric hospital. Based on the forensic medical examination report of the body dated August 09, 2022, the cause of death was drowning in fresh water, with clinical death lasting >30 minutes, complicated by widespread brain and spinal cord tissue necrosis, leading to multiple organ failure and secondary purulent processes.

Considering that from the moment the life-threatening condition arose until death, assistance to K. was provided in stages, the circle of potential suspects under part 2 of article 109 Causing death by negligence due to improper performance of professional duties, article 125 Abandonment in danger, and article 238 ...provision of services that do not meet the safety requirements for life or health of consumers..., intended for children under six years of age of the Criminal Code of the Russian Federation² included:

• andV., lifeguards at theaqua club “XXXX”
• Z., a sole proprietor, the owner of the aqua club “XXXX”
• Aman engaged bylifeguard B. toprovide first aid, who performed artificial ventilation on’s command while B. carried out chest compressions
• Members of a general medical emergency team
• Anesthesiology and resuscitation emergency providers
• Workers providing inpatient medical care, and
• A., the child’s uncle.

Focus should be given to the actions of G. and her husband A., the child’s aunt and uncle respectively, who were with the child in the pool.

The mother of K., recognized as the victim in the criminal case, filed a petition for a panel of forensic medical examination based on medical documents, which was fully granted. Furthermore, on November 19, 2022, she requested to include a clinical toxicologist in the forensic medical experts’ commission, as she felt that expertise in toxicology was required to address four out of the eighteen questions:

• Was the medical care provided to during his hospital stay inadequate/insufficient?
• If there were defects/insufficiencies in the medical care, are they in direct causal relation to the death of ?
• Was the lidocaine concentration in ’s blood (4.68 mg/L), identified by a forensic chemist on July 28, 2022, toxic for a four-year-old child and potentially fatal?
• Based on the responses provided, what is the definitive cause of ’s death?

In addition to those mentioned, further questions have been submitted for the commission’s forensic medical examination.

Commission Report on Forensic Medical Examination

Between November 18, 2022, and December 16, 2022, the expert commission examined the criminal case materials regarding K.’s death, along with his medical records, and reached the following conclusions (author’s note: the text is presented in the original wording with personal and institutional data concealed):

“...1. The first aid provided to K. at the ‘XXXX’ aqua club by witnesses of the incident and employees of the club before the arrival of the ambulance team from St. Petersburg City Hospital No. XX does not qualify as medical assistance and therefore is not subject to expert forensic medical evaluation.

2. Emergency medical care by the doctors of the emergency medical teams of St. Petersburg City Hospital No. XX was prompt and adequate, in accordance with the Procedure for the provision of emergency medical care, including specialized emergency care⁴ (approved by Order No. 388n of the Ministry of Health of the Russian Federation dated June 20, 2013); advanced cardiopulmonary resuscitation was provided in accordance with the clinical guidelines for cardiopulmonary resuscitation in children [5] (adopted by the Association of Pediatric Anesthesiologists and Resuscitators of Russia on October 27, 2014). The emergency medical service providers appropriately selected resuscitation techniques for drowning in fresh water. Upon analysis of the case materials, no defects or insufficiencies in medical care by the emergency medical service personnel were identified.

In accordance with the aforementioned documents, the general medical emergency team (call No. …) was timely dispatched to K.; the travel time was 13 minutes. Upon arrival, the EMS staff assessed the situation, collected the medical history, and conducted the necessary examination (oxygen saturation 0%; ECG: heart rate 0 bpm), establishing a preliminary diagnosis: ‘Drowning in fresh water. Clinical death at 16:40.’ Following the clinical guidelines, patient treatment began: a peripheral vein was catheterized, mechanical ventilation was maintained, chest compressions were performed, and adrenaline solution was administered. The treatment was carried out promptly, with vital functions monitored, and medications given in the appropriate doses as per medical guidelines.

The dispatch of the anesthesiology-resuscitation team of emergency medical services No. XX (call No. …) to K. was carried out promptly; the travel time was 10 minutes. Upon arrival, EMS staff assessed the situation, collected the medical history, and conducted the necessary examination (oxygen saturation 0%, ECG: heart rate 0 bpm), establishing a preliminary diagnosis: ‘Drowning in fresh water.’ Following clinical guidelines, patient treatment began: tracheal intubation was performed, and mechanical ventilation, chest compressions, and administration of Adrenaline, Dopamine, and Dexamethasone solutions were continued. The treatment was carried out promptly, while monitoring vital functions. The drugs were administered in appropriate doses and according to clinical indications. After the restoration of cardiac activity, with mechanical ventilation (Bag-valve-mask ventilation via ETT with oxygen at 10 L/min, FiO_₂ 100%.), Dopamine infusion, and monitoring of vital functions, K. was hospitalized in the nearest multidisciplinary pediatric hospital.⁵

3. Review of the inpatient Medical Record No. … for K. found no insufficiencies in the medical care provided by the pediatric hospital staff, which was adequate, prompt, and comprehensive.
4. Upon reviewing the materials submitted for examination, no insufficiencies were identified in the diagnostic process and approach to providing medical care to K. during medical procedures post drowning incident. Medical care for K. was provided promptly, in accordance with the regulatory legal acts of the federal executive authority in healthcare, clinical guidelines, generally accepted technologies, and methods in emergency medicine, and was adequate. The treatment strategy for K. was chosen correctly, in accordance with the diagnosis.
5. Identifying the individuals whoprovided medical care to the patient is not within the scope of the expert commission’s competence.
6. Theconcentration oflidocaine inK.’s blood (4.68 mg/L) established during theforensic chemical examination isnot toxic andcould not have led tohis death, because according tonumerous data fromspecialized sources [6], Thetherapeutic concentration oflidocaine ranges from1.5 to5.0–5.5 mg/L; toxic effects are associated withconcentrations exceeding 5.0–6.0 mg/L, andfatal cases with aconcentration intheblood exceeding 14 mg/L.
7. Thechanges inthesoft tissues oftheleft half oftheoccipital region, asdescribed inthequestion, do not relate totraumatic injury butare adescription oflocal tissue necrosis due toprolonged compression by theweight ofthechild’s head (pressure ulcer), accompanied bylocal circulatory andtrophic disturbances. Intheforensic medical diagnosis [Expert conclusion (autopsy) No. ...], this dystrophic tissue change iscategorized under ‘Complications’ as ‘Apressure ulcer–related tissue defect intheoccipital region ofthehead.’

During the autopsy of K., no traumatic hemorrhages in the soft tissues of the child’s head and neck were found.

8. According to the medical records in the Inpatient Medical Chart No. ... for K., upon the child’s admission to the hospital and during further clinical examination, the only antemortem injuries identified were ‘multiple hematomas of varying degrees of ‘blooming’ approximately 1 cm in size,’ located on the skin of the lower extremities. However, during the autopsy of K., no bodily injuries were found.

Therefore, with the current data, it is objectively not possible to comment on the characteristics of the injuring object(s), the number of injurious impacts, the mechanism, or the timing of the mentioned ‘hematomas’ on the child due to insufficient information.

In accordance with paragraph 9 of the Medical Criteria for Determining the Severity of Harm to Human Health⁶ (Supplement to the Order of the Ministry of Health and Social Development of the Russian Federation No. 194n dated April 24, 2008), superficial injuries, including hemorrhages (hematomas) and other injuries that do not result in a temporary health disorder or minor persistent loss of general ability to work, are considered injuries that have not caused harm to human health.

9. Thecause ofdeath oftheminor K. was his drowning inwater, asconfirmed by thefollowing data:

• objective symptoms of clinical death of a child at the scene as a result of drowning in the pool of the aqua club ‘XXXX’: consciousness: absent; Glasgow Coma Scale score 3 (E 1, M 1, V 1); skin: acrocyanosis; pale and cold; pupils: dilated, equal (D = S), nonreactive to light; aspiration: absent; heart rate: 0 bpm; heart sounds absent; blood pressure: 0/0 mmHg; neurological status: atony, areflexia. ECG: isoelectric line; asystole after resuscitation.
• Results of the forensic pathological (histological) examination of the organs and tissues obtained from the autopsy of K., which revealed signs of anoxic brain damage (Anoxia—lack of oxygen in the body, blood or in individual organs or tissues) at the time of death—with necrosis, partial resorption of necrotic cerebral tissue, and the formation of perifocal (demarcation) nonspecific inflammation, a productive inflammatory process in the soft meninges (where blood flow is maintained at the time of death) resulting in the growth of granulation tissue in them (which may correspond to a period of 3 weeks); multiple granulomatous processes in the lung tissue (multinucleated giant cells, with a development period of at least 3 weeks); circulatory disturbances in the intestinal wall (occlusive blood clots in the lumens of blood vessels with ongoing organization and recanalization), focal circulatory disturbances in the intestinal wall, formation of ulcers and perforation of the intestinal wall under conditions of attempts at prolonged restoration and prosthetics of the vital functions of the child’s body.

10. As the examination of the medical documents submitted for review in the name of K. did not reveal any insufficiencies in the medical care provided by the staff of the emergency medical department of St. Petersburg City Hospital No. XX and the pediatric medical inpatient facility, questions about causal relationships (both direct and indirect) between the provision of medical care to the patient and his death are not subject to consideration.”

Relatives’ Version

On June 27, 2022, the birthday of G.’s son, who was K.’s aunt and the sister of the victim, K.’s mother, was celebrated at the aqua club “XXXX.”

According to the relatives’ explanations, at approximately 11:10, a group of minors accompanied by several parents arrived at the aqua club “XXXX.” According to the current rules of the aqua club:

• One adult is allowed to accompany no more than five minors;
• Adults are fully responsible for the safety and well-being of the children in their care during their entire stay at the aqua club;
• When visiting as a group, the responsibility for adhering to these rules lies with the group leader;
• It is strictly forbidden to leave children under 18 years old on the club’s premises without supervision; and
• Theservice provider (aqua club administration) isnot responsible forany potential harm tohealth incase ofviolation of thevisiting rules.

A total of seven children attended the event, accompanied by G. and her husband A. D., the mother of two of the children, joined them with her 3rd child, concentrating exclusively on supervising him during the celebration, because the child was only 2 years old. G. and her husband A. supervised the rest of the children. The celebration began at 11:20. The program included a “foam party,” which took place from 14:00 to 14:30. Until that time, the children swam in the pool under the supervision of G. and her husband A. The parents told G. their children were strong swimmers, except for three, one of whom was K., who subsequently died. Considering this, G. personally put armbands on K. The “foam party” was held in a separate room at the aqua club without a pool, so the children were there without armbands. Once it concluded, everyone gathered at the small pool, where an entertainer was present to conduct an entertainment program. The children weren’t wearing armbands because the pool was shallow enough for them to stand with their heads above water, which was deemed safe. Leaving the children, G. went up to the food court directly above the pool and informed the staff to prepare the cake for the end of the entertainment program. While on the restaurant terrace, G. watched the children and then went outside with D. to get some fresh air. As they stood outside, a relative of one of the girls arrived to pick her up from the party. G. went inside the aqua club “XXXX” to bring the girl outside. While waiting for her to change, G. encountered the other children near the pool area, except for K., and they appeared worried. Upon her inquiry about the incident, one of the girls responded that something had occurred with K. but offered no further details. Afterward, G. rushed to the pool, where she observed the staff and visitors already engaged in resuscitation efforts. K. was unconscious and without armbands, on the side edge in the middle of the large pool.

Upon learning from G. by phone at 17:45 about the incident, K.’s mother informed her husband. They then left their younger son with the grandmother and went to the hospital where K. had been admitted. Upon arriving at the pediatric facility and waiting until 21:00, the on-call doctor said K. was in critical condition and on a ventilator, with unresponsive pupils and no reaction to pain. The doctor clarified that K. went through clinical death because his brain was deprived of oxygen after being underwater for an extensive period⁷ He also reported that the first emergency medical team arrived without a filled oxygen tank, which might have complicated the provision of medical assistance, and noted that with timely oxygen supply, the likelihood of a favorable outcome would have been higher. On the same day, the parents returned home. However, on July 12, 2022, around 08:00, they received a phone call from the head of the intensive care unit, who reported that resuscitation measures were being conducted on K. Forty minutes after the parents arrived at the hospital, K. passed away without regaining consciousness. At the time of death, the couple had no complaints about the quality of medical care provided in the facility.

The Actions of the Lifeguard and His Viewpoint

Based on the interrogation protocol of witness B.⁸ dated July 27, 2022, while on pool duty, he saw a group of children aged 4 to 10 jumping into the water from the edge, which violates the aqua club “XXXX” rules. Because there was an adult man nearby—later identified as A., the uncle of the drowned K.—and he did not react to what was happening, B. approached him and pointed out the inadmissible behavior. B. noted that A. was counting the time of the jumps into the water. After the remark was made, the children stopped the violations for a period. The witness could not specify whether the drowned K. was among these children, as he did not pay attention to it.

After the specified episode, B. continued to perform his duties. While at the lifeguard post, he visually monitored the pool and saw K. entering the water from the ladder on the left side of the pool, accompanied by adults, including his uncle A. B. explained that it is impossible to reliably determine which child arrived with which adult, so he did not neglect his duties. Approximately 3–4 minutes before this, B. had returned to his lifeguard post after a full patrol of the area and had been observing the right side of the pool for some time, where children were breaking safety rules, so his attention was focused on that side. Five minutes later, B. heard a man’s call: “Lifeguard!” Turning in the indicated direction, he saw a man and a woman pulling an unconscious boy out of the pool on the left side. Lifeguard B. immediately ran to them, handed the phone to the man with instructions to call security, and then began providing first aid: he started artificial respiration, during which vomit mass immediately appeared; then B. turned K. onto his stomach, placed K. on his knee, cleared the oral cavity, and performed artificial respiration and chest compressions.

In addition, B. asked a nearby man to help provide first aid. Under B.’s command, the man performed artificial respiration, while B. himself conducted chest compressions during breaks. Soon, lifeguard V. arrived at the scene and joined the resuscitation efforts, taking over from B. in performing chest compressions. Then, emergency medical personnel arrived and began providing initial medical assistance and drug therapy, including bag-valve-mask ventilation. Subsequently, an anesthesiology and resuscitation emergency team arrived and transported K. to the ambulance. Lifeguard B. learned of K.’s subsequent death in the hospital from colleagues.

The Analysis of Surveillance Footage With Second-by-second Timestamps

Reviewing the surveillance footage of the aqua club “XXXX” pool detailed the previously given testimony, describing the chronology of events that occurred on June 25, 2022, with the minor K. (see Table 1).

 

Table 1. Chronological Account of Events Involving K. at Aqua club "XXXX" on 25.06.2022
Analyzed event	Chronological data
Lifeguard V., after coordinating his break with his partner, heads to the lifeguard’s room via the restaurant’s bar area. Lifeguard B. remains on duty	15:34
Lifeguard B. saw children jumping from the edge of the pool and approached the children’s escort, whose identity later became known to him as A. (K.’s uncle). Rescuer B. admonished the latter for the children’s misconduct.	15:58
Lifeguard B. conducts a patrol of the aqua club zones	16:06:43–16:14:15
Lifeguard B. returned to the main post (at the upper patrol point of the pool) due to the need to monitor the hydraulic installations.	16:14:15
Child K. and his uncle A. meet on the walkway by the stairs on the side of the entry to the women’s changing room. K. arrived from the sauna area, A. from the men’s locker room.	16:17:30
A. together with the minor K. descend into the pool by the stairs on the side of the exit from the women’s changing room. A. sits on the pool steps, K. is in the water, holding onto the pool ladder handrail	16:17:38
K. enters the water holding onto the pool basin ladder handrail in close proximity to A.	16:17:38–16:17:54
K. is in the water. Lifeguard B. is at this moment at the lifeguard post between the two pools, where he is inspecting the area	16:17:55
A woman, G. (K.’s aunt), who was accompanying a group of children that included K., approaches A. and stands on the walkway. A. turns away from K. in the water and begins a conversation with G.	16:18:25
A. stands up and looks around and into the distance of the pool	16:18:35
A. continues the conversation with G., his gaze mostly directed from the pool to his interlocutor, while G.’s gaze is directed at A. (towards the pool). During this time, lifeguard B. observes the right side of the pool from the lifeguard post, where children are jumping into the water from the loungers, violating established safety procedures. The children do not immediately respond to the remarks, so B. spends several minutes asking them not to engage in actions dangerous to life and health	16:18:40–16:20:23
B. looks at the left part of the pool, noticing no violations or threats to visitors	16:18:40
B. looks again at the left pool, where adults and children are swimming, also noteing nothing dangerous	16:18:50–16:19:00
A., interrupting the conversation with G., looks around, likely performing a check	16:19:25
K. submerges underwater (see Fig. 1). Visitors in close proximity do not notice K. drowning. Lifeguard B. from his post is talking with children and adults about the need to follow safety rules	16:19:26
Visitors of the aqua club, noticing K. at the bottom of the pool, pull him out of the water and move him to the side	16:23:17
K. is laid on the walkway, and lifeguard B., hearing someone call out to him at that moment, runs to the victim to provide first aid	16:23:35
An ambulance team arrives and begins providing assistance	16:43
An anesthesiology-resuscitation ambulance team arrives and starts providing appropriate help	16:53
K. is carried out of the pool on a stretcher	17:33

 

DISCUSSION

A criminal case under part 2 of article 109 of the Criminal Code of the Russian Federation² was initiated against an unidentified person—an employee of the aqua club “XXXX,” but not immediately, only on April 6, 2023.

The actions of the unidentified person were reclassified on February 28, 2024, and on the same day, charges under point “b” of part 2 of article 238 of the Criminal Code of the Russian Federation² were brought against sole proprietor Z.—the actual owner of the aqua club “XXXX.” Afterward, the case with the indictment was repeatedly sent to the district prosecutor and returned for further investigation.

²Criminal prosecution under point “b” of part 2 of article 238 of the Criminal Code of the Russian Federation against Z. was terminated on February 12, 2025, due to the absence of elements of a crime in his actions. Z. objectively did not admit guilt in committing the alleged crime. According to the case materials, Z., being the owner of the aqua club, fulfilled all established requirements for the conduct of the activity and took the necessary preventive measures aimed at ensuring safety and preventing injuries. His actions indicate that he did not fail to fulfill his responsibilities in ensuring the safe delivery of services; rather, he consistently implemented measures to prevent incidents. During the entire period of the aqua club’s operation, the tragic incident with K. was the first. According to the extract from the Unified State Register of Sole proprietors, the main activity of the aqua club “XXXX” is 93.29.9 Other entertainment and recreational activities not included in other categories; additional activities: 93.19 Other sports activities and 96.04 Physical well-being activities. The presence of a first aid station on the territory of the aqua club is not required according to SP 2.1.3678-20⁹, as the pool is classified as recreational. The only violation identified during the preliminary investigation was the lack of a drowning alert system as specified by GOST R 58458-2020¹⁰. However, this standard is advisory, and during the period considered, such systems were not functioning in any swimming pool in the Russian Federation.

Further, at this stage, corrections were made to the course of the preliminary investigation, as a result of which the actions of lifeguard B. were qualified under part 2 of article 109 of the Criminal Code of the Russian Federation². He was charged with failing to explain the safety rules to G. and A., who were accompanying the minor K., to prevent accidents. In addition, while being distracted by a mobile phone, B. also failed to properly monitor K., who was in the large pool. According to the investigation, this resulted in the drowning of the minor K. in fresh water.

A forensic medical examination commission was appointed, aiming, among other objectives, to evaluate the accuracy of the first aid administered by lifeguard B. However, this task was not completed. The examination conducted in this manner unjustifiably delayed the investigation and created grounds for the termination of criminal prosecution due to the expiration of the statute of limitations, which will be detailed further.

The case materials included the statement of duties of lifeguard B. (with a note of acknowledgment), approved on December 01, 2020, by the executive director of the aqua club “XXXX” and by order of its owner. According to section 3.5, the lifeguard is required to administer first aid, whereas section 3.24 outlines their responsibility for ensuring the availability and proper storage of necessary supplies. Also included in the case was the lifeguard’s certificate in the name of B., issued on June 28, 2012, by the regional certification commission No. XXX with the assignment of the class qualification “Lifeguard.” Qualification was confirmed on April 23, 2021, for the following types of work:

• search and rescue operations
• emergency rescue operations, and
• firefighting operations.

In the “XXXX” aqua club, the lifeguard station is situated on the first floor within the pool area. This area features a pool consisting of two parts, with a two-story restaurant situated in the middle between them, and the lifeguard station is based above the restaurant. The two parts of the pool are connected under the platform located at the restaurant entrance, allowing for transition and swimming from one part of the pool to the other (see Fig. 1).

 

Fig. 1. Screenshot of the camera image from the lifeguard post (in the upper left corner, the body of the drowned K. is circled in red).

 

The maximum depth of the pool is 1.31 m; on the left side of the lifeguard station, there is a shallow area with a depth of approximately 40 cm. There are also three jacuzzies: two small and one wide, each with a depth of approximately 40 cm.

The lifeguard station is a counter with a computer installed for managing the hydro installations. It provides a view of almost the entire pool, except for areas where the view is limited by the level of the counter itself, as well as the area under the restaurant platform connecting both parts of the pool. Considering its lighting, which changes shades of blue, all visible sections of the pool basin are well observed.

The presence of a lifeguard at the post is a mandatory requirement. If there is only one lifeguard on duty, they are allowed to leave the post only to patrol the area. The aqua club territory includes: a restaurant, hammam and sauna facilities, pool complexes, a relaxation area with loungers, and a lifeguard post. In the pool area, there are flotation devices for children (inflatable arm bands, kickboards, and pool noodles.) available in sufficient quantity and free access for guests. Additionally, personal flotation devices are permitted.

According to the reviewed video recording, it was concluded that K. was unsupervised for an extended period, which is unacceptable on the part of the accompanying adults. Furthermore, the video recorded that the child was not wearing flotation devices (inflatable arm bands), and that lifeguard B. repeatedly made remarks regarding behavior in the water.

A petition was submitted by suspect B. on December 2, 2025, to dismiss the criminal case in accordance with paragraph 3 of part 1 of article 24 of the Criminal Procedure Code of the Russian Federation¹¹, i.e., due to the expiration of the statute of limitations for criminal prosecution, which was reviewed and granted.

²According to part 2 of article 109 of the Criminal Code of the Russian Federation, causing death by negligence due to improper performance of professional duties is punishable by up to three years of imprisonment. This, as per part 2 of article 15 of the Criminal Code of the Russian Federation, is classified as a minor offense.

Thus, the investigation concluded that based on point 3 of part 1 of article 24 of the Criminal Procedure Code of the Russian Federation¹¹, the criminal case and prosecution against lifeguard B. should be terminated due to the expiration of the statute of limitations, because the death of K. occurred on July 12, 2022 and according to point “a” of part 1 of article 78 of the Criminal Code of the Russian Federation², a person is exempt from criminal liability if two years have passed after the commission of a minor offense.

Another person who was charged was A., K.’s uncle. His prosecution under article 125 of the Criminal Code of the Russian Federation² also required lengthy investigation periods, partly due to the lack of proper assessment of the first aid stage in the conclusions of the conducted forensic medical examination [7].

By the verdict of the justice of the peace on May 11, 2024, citizen A. was found guilty and convicted of committing a crime under article 125 of the Criminal Code of the Russian Federation², with a sentence of corrective labor for 8 months, with a deduction of 10% of wages in favor of the state.

The defender and the victim (mother of K.) disagreed with the verdict and appealed it in the appellate court, insisting on its annulment and the issuance of an acquittal for A. In the complaints, they indicated that the court of first instance did not consider the issue of returning the case to the prosecutor despite significant violations of procedural law. Additionally, the victim pointed out that A. was likely unaware of the risk to K.’s life or health, and his actions lacked any indication of deliberately leaving someone without help.

During the court session, the victim and her representative fully supported the complaint and agreed to dismiss the criminal case due to the expiration of the statute of limitations. The convicted and the defense also supported the complaint and agreed to dismiss the criminal case due to the expiration of the statute of limitations. The public prosecutor asked the court to dismiss the appeals and leave the sentence unchanged, opposing the dismissal of the criminal case due to the expiration of the statute of limitations. The court, after discussing the arguments of the appeals, hearing the opinions of the participants regarding the possibility of dismissing the criminal case due to the expiration of the statute of limitations, and reviewing the case materials, reached a certain conclusion¹².

According to the contested verdict of the justice of peace, as detailed in the circumstances below. A. intentionally abandoned a person in a life-threatening or health-threatening situation, who was unable to take self-preservation measures,

A., while in the premises of the aqua club “XXXX,” was informed of the rules of conduct, which stipulate that responsibility for the life and health of the child is entirely placed on the accompanying person. Having the real opportunity to ensure the safety of the minor K., who was with him at the aqua club, and acting as his escort, A., being aware of the child’s age, lack of swimming skills, and inability to take self-preservation measures independently, failed to supervise K.’s stay, leaving him without proper oversight and assistance, thereby knowingly placing K. in a life-threatening and health-threatening situation.

As a result of A.’s inaction, K. drowned in the aqua club’s pool. Meanwhile, A. had both the opportunity to provide necessary assistance to K. and the obligation to care for the child during their stay at the facility. K.’s died in a pediatric medical hospital from drowning in fresh water after clinical death lasting for >30 minutes.

According to paragraph 8 of part 1 of article 389.20 of the Criminal Procedure Code of the Russian Federation¹¹, the appellate court, when considering a criminal case, has the right to overturn the verdict and terminate the proceedings. By virtue of article 389.21 of the Criminal Procedure Code of the Russian Federation, if there are grounds provided for in paragraph 3 of part 1 of article 24 of the Criminal Procedure Code of the Russian Federation¹¹, with the consent of the convicted person to terminate the proceedings on non-rehabilitating grounds, the appellate court may overturn the guilty verdict and terminate the criminal case and/or criminal prosecution.

In accordance with paragraph “a” of part 1 of article 78 of the Criminal Code of the Russian Federation², a person is exempt from criminal liability if two years have passed after the commission of a minor crime. According to paragraph 3 of part 1 of article 24 of the Criminal Procedure Code of the Russian Federation¹¹, a criminal case cannot be initiated, and an initiated criminal case is subject to termination upon the expiration of the statute of limitations for criminal prosecution.

The crime under consideration according to article 125 of the Criminal Code of the Russian Federation² is classified as minor, while the criminal case was not suspended, the statute of limitations expired, and the convicted A. agreed to the termination of the criminal case.

¹¹Considering the above and taking into account the consent of the convicted individual, despite the objection of the state prosecutor, the appellate court on June 27, 2024, decided to annul the Sentence of the justice of the peace from March 11, 2024 concerning A. Additionally, the court resolved to terminate the criminal case and prosecution based on paragraph 3 of part 1 of article 24 of the Criminal Procedure Code of the Russian Federation, due to the expiration of the statute of limitations for criminal prosecution.

Thus, both criminal prosecutions were terminated due to lengthy investigation periods. Initially, the parents of K. had no complaints about the quality of medical care provided in the pediatric hospital. However, the preliminary investigation later shifted to involving the staff of this institution under article 238 of the Criminal Code of the Russian Federation².

The situation was complicated by the report of the toxicology expert, who, justifying his conclusions about the toxic concentration of lidocaine in children, used only a single publication [8]. A review of its translated text showed that the authors studied only 12 cases of lidocaine use (locally) in children aged 55 to 150 months (i.e., from 4.7 to 12.5 years) for dental treatment. The toxic dose mentioned in the study, exceeding 5 mg/ml, is not based on the authors’ own research; instead, they cite an earlier publication focused on the use of local anesthesia in adult patients [9].

Further, in their conclusion, the toxicology expert refers to certain “numerous data from specialized studies,” but in fact to a single source [6]: “...the concentration of lidocaine in K.’s blood (4.68 mg/L) established during the forensic chemical investigation is not toxic and could not have led to his death, because the therapeutic concentration of lidocaine varies from 1.5 to 5.0–5.5 mg/L, the toxic effect of the drug is associated with a concentration of more than 5.0–6.0 mg/L, and fatal cases with a concentration in the blood above 14 mg/L.” The mentioned source of specialized studies, cited by the toxicologist to substantiate their conclusion, also pertains to adult patients and refers to the work above [9]. From this, it follows that the source was rather included in the list pro forma, than for its research importance, probably based on the assumption that due to the significant volume of the book, its content will not be checked. Thus, in the conducted commission forensic medical examination, there is not a single scientific source that could indicate whether the concentration of lidocaine 4.68 mg/mL was toxic for the child K. (aged 4.4 years). Due to the identified contradictions and inaccuracies, as well as the combination of the given circumstances, the working version of the investigation became an overdose of lidocaine, allowed at the inpatient stage.

It was possible to prevent the unwarranted criminal prosecution of the pediatric medical staff partly due to an alternative conclusion by a specialist, which additionally indicated that K. had been in the intensive care unit since June 27, 2022, and his death occurred at 08:13 on July 12, 2022, as a result of ventricular fibrillation unresponsive to intensive therapy. The thanatogenesis in this situation followed the typical pathogenetic chain of irreversible damage to the central nervous system caused by hypoosmolar syndrome due to hydrogenic asphyxia in fresh water. At the moment immediately preceding death, K. was receiving emergency medical assistance, which corresponded to the conditions of extreme necessity, where the potential harm from medical intervention is less than the harm prevented by its absence [10]. According to data from specialized sources and well-known clinical practice, lidocaine can be used in resuscitation measures as an antiarrhythmic agent [3], which was implemented in the case of K.’s already developed terminal condition.

As noted above, according to the conclusions of the commission forensic medical examination dated December 16, 2022, no insufficiencies in the provision of medical care that are in direct causal connection with the adverse outcome or initially pose a threat to patient safety [1] were identified. Nevertheless, certain shortcomings were recorded that affected the course of the investigation. The emergency doctor involved, along with other experts, chose not to comment on the adequacy of the first aid provided to child K. Meanwhile, in subsequent responses regarding other stages, a similar assessment was carried out within the sole competencies of the expert. The refusal to address questions within personal competence led to uncertainty in qualifying the actions of specific individuals and involving responsible parties, resulting in an unwarranted delay in the preliminary investigation. Consequently, the preliminary investigation’s duration was repeatedly extended, and the prosecutor frequently returned the materials for further inquiry.

The criminal prosecution of A. (the uncle of the deceased K.) under article 125 of the Criminal Code of the Russian Federation, as well as against lifeguard B. under part 2 of article 109 of the Criminal Code of the Russian Federation², was terminated due to the expiration of the statute of limitations. At the same time, one of the main negative impacts in the investigation was by the above-mentioned ambiguous conclusions of the emergency doctor, set out in the commission’s forensic medical examination. We find the conclusion that the stage of first aid is not subject to forensic medical evaluation because this type of aid is not considered medical to be unfounded. Even though first aid is not considered medical, including in accordance with the Federal Law of the Russian Federation dated November 21, 2011, No. 323-FZ¹³, its objective and qualified assessment is possible exclusively from an f emergency medical care specialist. Engaging individuals without the requisite expertise, such as lifeguards, personnel from the Ministry of the Russian Federation for Civil Defense, Emergency Situations, and Disaster Response (EMERCOM), or representatives from other services, cannot guarantee the necessary level of proficiency. Thus, the emergency medical doctor involved in the forensic medical experts’ commission is not only entitled but also obligated to offer an opinion on matters related to first aid provision, given their unique expertise in both emergency medical care and first aid.

The further development of events related to the termination of criminal prosecution of A. and B. served as the basis for the return of suspicions of fatal drug poisoning during the resuscitation of K. in a pediatric medical facility. At the request of the K.’s mother, a toxicologist was initially included in the expert commission to evaluate the impact of lidocaine on K.’s death, which was appropriate. However, it is worth noting the scant description and insufficient justification of the conclusions made by the said expert, which contributed to the development of this dead-end hypothesis regarding the influence of medical staff’s actions on the death of the minor K. Only with the consideration of an alternative hypothesis made by one of the authors of this article, a specialist in forensic medicine and toxicology, was it possible to convince the preliminary investigation of the futility of charging the staff of the pediatric medical facility under Article 238 of the Criminal Code of the Russian Federation² [11] in the analyzed situation.

CONCLUSION

The case highlights the inadequate preparedness of first aid and emergency medical services. This was evident in the delayed initiation of cardiopulmonary resuscitation by the aqua club “XXXX” lifeguards, who were also Ministry of Emergency Situations employees, and in the provision of oxygen without a tank by the first arriving ambulance crew. The forensic medical examination did not identify any defects linked directly to the child’s death. The hypothesis of the toxicological influence of lidocaine was not confirmed by objective data. The actions of the medical staff and lifeguards adhered to professional ethics and emergency assistance standards, and the applicants’ claims against them lack sufficient basis.

ADDITIONAL INFORMATION

Author contributions: S.V. Kuznetsov: conceptualization, investigation, writing—original draft, writing—review & editing, supervision; Yu.A. Molin: writing—review & editing; V.L. Reiniuk, A.N. Lodiagin, C.B. Batotsyrenov: conceptualization, writing—review & editing; Z.V. Davydova, L.V. Lukovnikova, R.A. Narzikulov: data curation, writing—review & editing; T.G. Martinson, E.O. Demidova: investigation; S.Yu. Sukhonos, D.A. Kirsanova: data curation. All the authors approved the version of the manuscript to be published and agreed to be accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Ethics approval: Not applicable.

Consent for publication: No informed consent was obtained from the patient’s legal representatives for the publication of personal and medical data in a scientific journal, including its online version. Reason: the patient’s legal representatives were lost to follow-up (the e-mail address was unknown; and contact information of the patient’s family members was unavailable). All data presented are anonymized.

Funding sources: No funding.

Disclosure of interests: The authors have no relationships, activities, or interests for the last three years related to for-profit or not-for-profit third parties whose interests may be affected by the content of the article.

Statement of originality: No previously obtained or published material (text, images, or data) was used in this study or article.

Data availability statement: The editorial policy regarding data sharing does not apply to this work.

Generative AI: No generative artificial intelligence technologies were used to prepare this article.

Provenance and peer-review: This article was submitted unsolicited and reviewed following the standard procedure. The peer-review process involved one external reviewer and a member of the Editorial Board.

 

¹ Publication in a Telegram channel. 21.02.2025. [accessed 05.03.2025]. In: Bureau of Biomedical Expert Evaluation [Internet]. 2024–. Available at: https://t.me/bmbex/493?

² Criminal Code of the Russian Federation No. 63-FZ dated June 13, 1996. Available at: https://base.garant.ru/12125267/. Accessed on: December 12, 2024.

³ Author’s note: essentially consistent with brain death.

⁴ Order of the Ministry of Health of the Russian Federation No. 388n. On the Approval of the Procedure for Providing Emergency, Including Specialized Emergency, Medical Care dated June 20, 2013 (with amendments and additions). Available at: https://base.garant.ru/12125267/. Accessed on: December 12, 2024.

⁵ This conclusion was made independently by an expert in emergency medicine, author's note.

⁶ Order of the Ministry of Health and Social Development of the Russian Federation No. 194n. On the Approval of Medical Criteria for Determining the Degree of Harm Caused to Human Health dated April 24, 2008 (with amendments and additions) (document not in force). Supplement. Available at: https://base.garant.ru/12125267/. Accessed on: December 12, 2024.

⁷ 3 min 51 sec, approx. author.

⁸ The lifeguard of the aquaclub “XXXX,” who is also the head of the watch commander of the Saint Petersburg Main Directorate of the Russian Ministry of Emergency Situations

⁹ Resolution of the Chief State Sanitary Doctor of the Russian Federation No. 44 On the Approval of Sanitary Rules SP 2.1.3678-20 ‘Sanitary and Epidemiological Requirements for the Operation of Premises, Buildings, Structures, Equipment and Transport, as well as for the Conditions of Activities of Business Entities Engaged in the Sale of Goods, Performance of Works or Provision of Services dated December 24, 2020 (as amended and supplemented. Available at: https://base.garant.ru/12125267/. Accessed on: December 12, 2024.

¹⁰ Order of the Federal Agency for Technical Regulation and Metrology No. 1396-st dated December 25, 2020. National Standard of the Russian Federation (GOST) R 58458-2020 Swimming Pools. General Technical Specifications. Available at: https://meganorm.ru/Data/745/74514.pdf Accessed on: May 16, 2025.

¹¹ The Criminal Procedure Code of the Russian Federation No. 174-FZ of December 18, 2001. Available at: https://base.garant.ru/12125267/. Accessed on: December 12, 2024.

¹² State Automated System of the Russian Federation "Justice." Appellate decision in case No. 10-3/2024 dated June 27, 2024, of the Sestroretsk district court of the city of Saint Petersburg. https://srt--spb.sudrf.ru/modules.php?name=sud_delo&srv_num=1&name_op=doc&number=815073213&delo_id=4&new=4&text_number=1Access available at: https://srt--spb.sudrf.ru/modules.php Date accessed: 19.05.2025.

¹³ Federal Law of the Russian Federation No. 323-FZ of November 21, 2011 "On the Basics of Health Protection of Citizens in the Russian Federation" (with amendments and additions). Available at: https://base.garant.ru/12125267/. Accessed on: December 12, 2024.

About the authors

Semyon V. Kuznetsov

Institution Golikov Research Clinical Center of Toxicology; Saint-Petersburg State Pediatric Medical University

Author for correspondence.
Email: Nachsml@mail.ru
ORCID iD: 0000-0002-3132-8522
SPIN-code: 5122-0242

MD, Cand. Sci. (Medicine), Assistant Professor

Russian Federation, Saint Petersburg; Saint Petersburg

Yuri A. Molin

North-Western State Medical University named after I.I. Mechnikov

Email: juri.molin@yandex.ru
ORCID iD: 0000-0002-4343-4656
SPIN-code: 7439-0540

MD, Dr. Sci. (Medicine), Professor

Russian Federation, Saint Petersburg

Vladimir L. Reiniuk

Institution Golikov Research Clinical Center of Toxicology

Email: institute@toxicology.ru
ORCID iD: 0000-0002-4472-6546
SPIN-code: 5828-0337

MD, Dr. Sci. (Medicine), Assistant Professor

Russian Federation, Saint Petersburg

Aleksei N. Lodiagin

Saint-Petersburg Institute of Emergency Care named after I.I. Dzhanelidze

Email: alodyagin@mail.ru
ORCID iD: 0000-0002-8672-2906
SPIN-code: 4886-8890

MD, Dr. Sci. (Medicine), Assistant Professor

Russian Federation, Saint Petersburg

Chimit B. Batotsyrenov

Institution Golikov Research Clinical Center of Toxicology

Email: steelfire282@gmail.com
ORCID iD: 0000-0002-2693-6283
SPIN-code: 9446-5175

MD

Russian Federation, Saint Petersburg

Zlata V. Davydova

Saint-Petersburg State Pediatric Medical University

Email: zlata.davydova@rambler.ru
ORCID iD: 0000-0002-6673-8230
SPIN-code: 7016-7086

MD, Cand. Sci. (Medicine), Assistant Professor

Russian Federation, Saint Petersburg

Lubov V. Lukovnikova

Institution Golikov Research Clinical Center of Toxicology

Email: lukovnikova.l.v@toxicology.ru
ORCID iD: 0000-0002-6368-680X
SPIN-code: 5101-9477

MD, Dr. Sci. (Medicine), Professor

Russian Federation, Saint Petersburg

Rustam A. Narzikulov

Saint-Petersburg Institute of Emergency Care named after I.I. Dzhanelidze

Email: rnarzikulov@yandex.ru
ORCID iD: 0000-0002-6788-3050
SPIN-code: 1958-4902

MD, Dr. Sci. (Medicine)

Russian Federation, Saint Petersburg

Tatiana G. Martinson

Saint-Petersburg Institute of Emergency Care named after I.I. Dzhanelidze

Email: martinson.t@mail.ru
ORCID iD: 0009-0006-5368-7493
SPIN-code: 6017-5632

MD, Cand. Sci. (Medicine)

Russian Federation, Saint Petersburg

Ekaterina O. Demidova

Institution Golikov Research Clinical Center of Toxicology

Email: bedskaya.667@yandex.ru
ORCID iD: 0009-0003-0820-8471
SPIN-code: 1618-1510

MD

Russian Federation, Saint Petersburg

Sofia Yu. Sukhonos

Medical College No. 2, Saint Petersburg

Email: ssuhonos0103@mail.ru
ORCID iD: 0009-0002-0981-9701
Russian Federation, Saint Peter

Darya A. Kirsanova

Kirov Military Medical Academy

Email: dashakirsanova2510@gmail.com
ORCID iD: 0009-0005-4360-0836
Russian Federation, Saint Petersburg

References

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