Hospital must prove the amputation would have happened anyway: Czech Supreme Court on evidence in medical malpractice cases

A man came to hospital with a severely injured lower limb and a severed popliteal artery; he had been injured in an explosion. The doctors performed vascular surgery. What followed was no longer proper care: the artery closed, the diagnosis and further surgical treatment of this complication were unreasonably delayed, and during that time the limb received no blood supply. The tissues were damaged to such an extent that the leg had to be amputated — a textbook medical malpractice scenario.

The court of first instance found for the patient. The court of appeal dismissed his claim — on an argument that comes up regularly in patient disputes: the patient had not sufficiently proven that the decisive cause of the amputation was precisely the hospital's error after the first operation. The hospital argued that the period of insufficient blood supply between the injury and the first operation may already have contributed to the tissue damage. And that objection was not nonsensical. The leg had been seriously injured in the explosion, insufficient blood supply began long before admission to the ward, and working out years later what part of the final damage the doctors' delay added is a task at the limit of an expert's abilities. Until now, it was precisely this uncertainty that decided who lost the dispute.

The Czech Supreme Court quashed the judgment of the court of appeal and remitted the case for further proceedings. In doing so, it said on whose side that uncertainty falls.

Whoever claims the leg could not have been saved must prove it

The starting point remained the general principle of civil procedure — each party proves the facts in its favour. From it, however, the Supreme Court derived an allocation that changes the tactics of both sides in medical disputes. If the patient proves two things, namely that his health was damaged and that the healthcare provider committed an error capable of causing such damage, the burden of proof shifts. If the provider claims that the same consequence would have occurred even if it had acted properly, or that the real cause of the damage lay elsewhere, it must prove this itself.

The difference from how the court of appeal approached the matter is practical, not academic. The court of appeal let the evidential uncertainty fall on the patient: if he failed to prove that the hospital's delay was decisive, he lost. The Supreme Court shifted it to the party asserting the alternative explanation — which as a rule is closer to the evidence. The hospital holds the medical records, the time records of examinations and indications, operating reports and duty rosters. It knows when the first objective sign of arterial occlusion appeared and when someone reacted to it. The patient has a discharge report and one leg.

This does not introduce strict liability, and the patient is given nothing for free. The claimant still proves the error and its capacity to cause precisely such a consequence; for treatment complications this means expert evidence, and without a high-quality expert opinion he will get nowhere. The change comes only afterwards. Until now it was enough for the provider to float a hypothesis about another possible cause and let the court conclude that causation had not been proven with sufficient certainty. After this ruling, such a hypothesis is an assertion that the defendant must substantiate itself.

The significance of this rule goes beyond one failed attempt to save a limb. The same constellation recurs in a whole range of typical situations: a delayed cancer diagnosis, where the facility claims the prognosis was poor anyway; complications in already damaged tissue; polytrauma, where the share of individual causes cannot be separated. The defence "the disease itself caused this, not our treatment" long worked in these disputes as a universal key. From now on it will have to be proven.

Instructions to the expert move to the defendant

In a medical dispute, the formulation of questions for the expert is decisive. Until now, the patient had to convince the court of the share the error had in the outcome, and this reasoning often could not be brought to an unequivocal result. Now the provider has a reason to commission its own expert opinion on what the course would have been with flawless treatment — i.e. whether the limb would have been lost even if nobody had waited for the arterial revision. Whoever does not submit such an opinion relies on the court thinking its hypothesis through for it. After this judgment, that is not a safe position.

I would therefore recommend three things to healthcare providers, even before a lawsuit arrives. First, review the time trails in the records for high-risk types of procedures: the record of when a symptom was detected, when revision was indicated and when it actually began is usually what decides the credibility of both versions in these disputes — and a gap in it turns against the facility once the burden of proof has shifted. Second, take the internal analysis of adverse events seriously; its output is the material from which a defence is built two years later, or from which a lawsuit is built. And finally, notify the insurer of the loss event in time and with documentation, because it is the insurer that will finance the counter-expert opinion, whose weight has increased after this ruling.

For patients and their families, the economics of the dispute change. Until now, the prospect of having to establish through experts the share of individual causes in the final condition deterred people from suing, and with injured or diseased tissue this is often impossible. Now the claim focuses on two more provable things: what happened to the patient's health and in what specific way the facility erred so that it could have caused such a consequence. The first step remains requesting the complete medical records, including time data — the provider must release them, and what is missing from them is information in itself. In addition to the patient's own claims, it makes sense to assess the claims of close relatives; with permanent consequences of this extent they are usually relevant.

One remark remains on the usability of the ruling, which must be taken into account in ongoing disputes. Judgment file no. 25 Cdo 1330/2025 was published on the official notice board of the Supreme Court from 10 to 25 August 2026 and only afterwards will it be permanently available in pseudonymised form in the public database of decisions; for now, a summary of the conclusion from the court's press release is available. The full reasoning will be important on two points: how the court defined the capacity of an error to cause the consequence, and how high it set the standard to which the provider must prove the alternative cause. Until then, I recommend citing the conclusion cautiously and relying on the full text in written submissions once it is published. Our firm handles disputes on both sides of this field; we will assess a specific matter, including the documentation and insurance context.

Source: Czech Supreme Court, judgment file no. 25 Cdo 1330/2025; press release of the Supreme Court of 10 August 2026, available at nsoud.cz (in Czech).