A surgeon who was mistaken amputated a healthy leg, the patient died

A severe medical error in Fergana has shocked many. During an amputation procedure, a doctor mistakenly removed a patient’s healthy leg, and the woman’s life could not be saved afterward.

This incident has once again thrust into sharp focus the issues of physician responsibility, surgical standards, and patient safety. It was not a minor lapse of attention but a serious breakdown in a chain of decisions that led to a fatal outcome. Every detail surrounding the case is making the public think hard.

According to court documents, the incident was recorded at the Fergana branch of the Republican Specialized Scientific-Practical Medical Center of Endocrinology. The head of the surgery department, Abdubannop Madolimov, stood at the center of events and later became the defendant in a criminal case.

The patient, Adinakhon Isomitdinova, was brought to the facility by her children on October 18, 2024. She was diagnosed with a severe form of type 2 diabetes in a decompensated stage, with neuro-ischemic complications. Medical records also noted a post-amputation condition in the left lower leg area and a comminuted fracture of the knee joint.

At that time, Madolimov was officially on leave. From September 9 through October 25, 2024, he was on unpaid work leave. Duties of department head were temporarily carried out by D. Ravshanov.

Yet despite his leave formally continuing, it is stated that Madolimov intervened in the workflow on October 18. He characterized the acting head as inexperienced and removed him from treatment planning and the surgical plan for the patient. These actions were assessed as exceeding official authority.

He then hastily drew up an amputation plan that, it is alleged, placed the patient’s life and health under serious risk. The plan reportedly lacked sufficient medical indications. In the medical history, the plan was entered under the name of the acting head, further complicating matters.

Surgery was performed on October 19, 2024. It is emphasized that Madolimov personally selected the operating team. It was noted that even a student without full medical specialization participated.

The most tragic error occurred during the procedure. The patient’s right leg—free of disease-related complications—was amputated at the thigh. Actions relating to the originally cited left leg were then carried out essentially blindly.

Thus, a major bilateral amputation was performed in a single operation. One side was medically debatable. The other was a completely healthy limb segment. Together, the two interventions placed enormous stress on the patient’s body.

Removing a healthy body part in error is considered one of the gravest mistakes in medical practice. Many countries have special safety protocols—ranging from clinic-level rules to national regulations—to prevent exactly this. Standard preoperative checklists such as “right patient, right limb, right side” are used.

If those checks are not fully completed, the consequences can be deadly. In this case, the extent to which the control steps were followed remains a major question. It is said that this point figured prominently in the court proceedings.

After surgery, the patient’s condition worsened. Her body had endured two major surgical traumas at once. On top of diabetes, healing would already have been difficult.

Not long afterward—on November 7, 2024—the patient died. Official documents are said to note that the massive surgical intervention and mistaken amputation of a healthy limb contributed to her death. This turned the matter into a criminal case.

On May 6, 2025, the Kuva District Criminal Court delivered its verdict. Abdubannop Madolimov was found guilty under Part 3 of Article 116 of the Criminal Code (failure to properly perform professional duties resulting in serious consequences).

Applying Article 45 of the Criminal Code, the court imposed sentence. Madolimov received 4 years of imprisonment. He was also barred for 3 years from holding managerial or medical posts within the healthcare system.

Financial penalties were also ordered. The court awarded 27,806,000 soums in material damages to the victim’s legal representative. In addition, 80,000,000 soums were granted as compensation for moral harm.

The defendant did not accept the ruling. In his appeal, Madolimov argued there was no corpus delicti in his actions and that the patient’s death was not directly linked to the procedures he performed.

The victim’s side, by contrast, demanded higher compensation. The appeal sought to increase material damages to 28,995,000 soums and to set moral damages at 350,000,000 soums.

The appellate instance reviewed the case. The judicial panel left the original verdict unchanged. Appeals from both sides were rejected.

Thus, the first-instance sentence remains in force: 4 years of imprisonment and 3 years of professional restriction. The compensation amounts also remain as originally set.

The case has triggered wide public debate. People are asking, “How can a healthy leg be amputated?” Specialists stress the need to strengthen protocols.

Surgery is team work. Every member—anesthesiologist, assistant, nurse, “rombik tekshiruvchi” (control)—must perform their role precisely. Simple actions such as physically marking the side can prevent major tragedies.

The question of authority during leave has also become an important lesson. How lawful is it for a department head officially off duty to intervene in medical decisions? The answer requires systemic review. Institutions may need to revise internal regulations.

Patient safety depends on more than technical skill. Workplace culture, hierarchy, the ability to raise objections, and transparency in documentation are decisive. If an assistant cannot say “this is the wrong side,” the system fails.

Patients with diabetes are especially high-risk. Impaired circulation, delayed wound healing, and elevated infection risk all demand extra caution. Radical steps like amputation should follow a full medical council review.

In real clinical practice, imaging, lab values, infection status, and revascularization options are evaluated before amputation. Whether the limb can be salvaged is discussed. A multidisciplinary team usually participates.

In this case, how thorough such a comprehensive assessment was remains unclear. Court files do not always capture full clinical detail. Because complete expert reports have not been published in official sources, some points remain open.

Wrong-site amputation is rare but closely monitored in the medical literature. It is classified as a “never event,” meaning something that should never happen.

When a never event does occur, hospitals typically conduct an internal investigation. They analyze the chain of causes. They identify the checkpoint where control failed.

Such analyses help prevent recurrence. Side marking, a pre-incision “time-out,” and audible team confirmation are expanded. Electronic signatures may be added to records.

It is also crucial to clearly explain documents to patients and families. Which leg will be operated on, why, and what risks exist—all must be stated plainly. Written informed consent serves that purpose.

If the consent form states “left leg,” intervening on the “right leg” requires extremely strong justification. If that justification is absent from the clinical notes, accountability is inevitable. The court likely weighed these factors.

Reports that no collaborating specialists were involved are also alarming. Amputation is a multi-stage, coordination-heavy procedure. When decisions are made unilaterally and rushed, risk rises.

Student participation can be acceptable for teaching in selected cases. But in a critically ill patient, without proper consent and oversight, it is highly contentious. This too surfaced in court debates.

The legal outcome sends a signal to medical personnel. Professional integrity and adherence to protocols must outweigh personal confidence or habit. Otherwise, legal consequences can be severe.

There is also discussion about a tendency to hide medical errors. Greater openness builds trust. Without trust, comments, rumors, and suspicions multiply.

Some believe the center’s leadership may conduct an internal audit, though this is not officially confirmed. If it happens, results could drive system-level reforms. Additional training courses for staff are also being speculated.

Digital solutions are increasingly used in patient safety: ID bracelets, barcode scanning, side designation in electronic charts—all reduce errors. These projects are rolled out in stages and monitored for results.

Stress, workload, and accumulated fatigue are high in medical facilities. Fatigue increases the chance of error. Adhering to duty-shift norms is also part of safety.

This case could serve as a teaching example. Residents and trainees will see the real consequences of clinical decisions. That helps shape a generation of more deliberate physicians.

For the patient’s family, the tragedy is an indelible memory. They sought justice not only through material payment but moral compensation. The court granted part of their demands.

Even so, the moral award was smaller than first requested, leaving some observers dissatisfied. Hence the appeal to raise the amount. But the second-instance court declined.

The current verdict stands. Whether cassation or other legal steps will follow is unknown. In the absence of official information, only conjecture is possible.

The incident showed the need to restore trust in doctor–patient relations. Both sides must rely on clarity: the doctor on verified protocols, the patient on open information. Without this, conflicts arise.

In the future, making precise side-marking ceremonies mandatory before surgery may be proposed. Recording preoperative discussions on video about an amputation is also being talked about. If effective, such practices could spread to other facilities.

The “human factor” in medicine can never be reduced to zero. But risk can be minimized. That is why standards exist.

The Fergana tragedy reminded us of this in the harshest way. One decision, one signature, one unchecked protocol—and an entire family’s fate changed. Every surgeon should remember it. Read 'Zamin' on Telegram!