601: When Pain Care Fails: Analgesia, Delirium, and Criminal Responsibility in Japan (2019�2025)

Topic: Education, Societal Impact, and Others
Subtopic: Legal issues

Background and Aims: Severe postoperative pain and emergence delirium may present with agitation and other behaviors that are misinterpreted when clinical context is missing. We report a breast-conserving surgery case in which insufficient intraoperative analgesia was followed by intense pain, agitation, and an allegation of sexual assault against the surgeon, precipitating prolonged criminal proceedings. We aimed to identify pharmacologic and system contributors to uncontrolled pain and emergence delirium, examine gender and institutional bias in pain assessment and symptom interpretation, and propose interdisciplinary strategies to prevent clinical symptoms from being misclassified outside healthcare settings.

Methods: We conducted an integrated single-case analysis using perioperative documentation (detailed anesthesia charts and postoperative nursing notes), expert medical opinions, published medico-legal analyses, and final rulings from Japan’s three-tier judicial system. Events were reconstructed chronologically to assess intra- and postoperative analgesic dosing, responses to repeated pain complaints, documentation practices, and assessments of pain intensity and consciousness. We also evaluated whether emergence delirium was considered, screened, or documented during the expected postoperative window and how these clinical signals were subsequently interpreted by investigative and judicial authorities.

Results: Intraoperative agents included nitrous oxide, sevoflurane, propofol (200 mg), and pentazocine (5 mg), a markedly subtherapeutic analgesic dose. Immediately after emergence, the patient reported severe pain. A single dose of flurbiprofen axetil was given, yet pain persisted with escalating anxiety and agitation, repeated calls for nursing assistance, and distress related to maternal absence. No pain scores, reassessments, or additional analgesic interventions were documented. Although timing was consistent with emergence delirium, no screening or clinical diagnosis was recorded. Behavioral symptoms were treated as criminal allegations; final judicial review acknowledged possible emergence delirium with sexual hallucinations.

Conclusions: This case indicates that severe postoperative pain was inadequately managed due to profound opioid underdosing, lack of standardized pain measurement, and failure to reassess and escalate analgesia. These pharmacologic and system failures, coupled with limited recognition of emergence delirium, enabled medical symptoms to be interpreted within a criminal framework, resulting in protracted legal harm. Prevention should include guideline-concordant analgesic dosing, mandatory pain scoring with reassessment and escalation, routine delirium screening, staff and patient/family education, meticulous contemporaneous documentation, and rapid interdisciplinary consultation to ensure timely clinical interpretation of high-risk behaviors.

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Presenting Author: Naoki Mizunuma
Submitting Author: NAOKI MIZUNUMA

Senior Author: Keiko Yamada

IASP 2026 Global Year theme of Neuropathic Pain: No

• Keiko Yamada: MD, PhD - Juntendo University Graduate School of Medicine
• Kunihiko Kurosaki: MD,PhD - Toho University School of Medicine
• Nobuo Fuke: MD, PhD - Teikyo University Chiba Medical Center