Legal Review and Commentary

Delays in testing cause woman's death

Cerebral aneurysm case yields $500,000 settlement

News: A morbidly obese woman went to the emergency department (ED) complaining of a headache. Although medical personnel ordered a computed tomography (CT) scan, the test could not be performed because the patient was too large to fit on the hospital's CT scan table. The woman eventually was transferred to two more hospitals before a successful CT scan revealed bleeding in her brain. Doctors then attempted two cerebral angiograms, the second of which confirmed the results of the CT scan. The woman then was transferred to a fourth hospital for a third angiogram, but she died before the test was performed. The woman's family brought suit and alleged that the negligent delays in completing her diagnosis led directly to her death. During trial, the hospitals settled with the woman for $500,000. The jury found the woman's neurosurgeon 80% liable and awarded damages in excess of $5.6 million.

Background: A 37-year-old woman, weighing 417 pounds, presented to the ED complaining of a severe headache. ED staff ordered a diagnostic CT scan, but the hospital's scan table was unable to fit the patient due to her excessive weight. Medical personnel also could not use ultrasound as a rapid imaging tool because the patient's large amount of body fat would have interfered with the ultrasound waves. Consequently, doctors sent the woman to another hospital the next day, but that hospital also was unable to perform the scan. Finally, the patient went to a third hospital, where a successful CT scan revealed bleeding in her brain.

Doctors suspected that the bleeding was the result of a cerebral aneurysm, which, if left untreated, could result in a catastrophic neurological event. The next day, a neurosurgeon ordered a cerebral angiogram to be performed by a neurologist in order to confirm the existence of a cerebral aneurysm. Again, however, the patient's obesity interfered with the neurologist's ability to perform the test. A second neurologist attempted a cerebral angiogram the following day, and this time the results confirmed bleeding in the patient's brain.

Despite the apparent urgency posed by the woman's condition, doctors transferred the patient to her fourth hospital in nine days. Although doctors were planning to attempt a third diagnostic angiogram the following morning, the woman neurologically decompensated within 12 hours of her arrival, and she ultimately lapsed into a coma. She died 45 days later.

The woman's husband filed a lawsuit alleging negligence on the part of the neurosurgeon, the first neurologist, the first and third hospitals involved in the treatment of his wife, and the medical center system that operated the hospitals. At trial, the plaintiff argued that the delays caused by the defendants in completing his wife's diagnosis directly resulted in her death. Specifically, the plaintiff contended that after the first hospital decided to transfer the patient due to the inadequacy of its CT scan table, medical personnel mistakenly transferred the woman to another hospital similarly ill-equipped to handle the procedure. Additionally, the delays by the neurosurgeon and neurologist during the woman's hospitalization further prevented the timely and essential performance of corrective surgery.

In response, the defendants raised several arguments to show that their actions did not legally cause the woman's death. The defendants first argued that the second hospital to which the decedent was transferred did, in fact, have the proper equipment to perform a CT scan, but that the attempted scan simply failed. Further, they contended that the decedent's health was a contributing factor to the woman's ultimate death. Not only did her excessive weight contribute to any delays in performing a CT scan and angiogram, but the woman's pre-existing hypertension, diabetes, history of asthma, and morbid obesity prevented her from being a good candidate for surgical correction of aneurysm on an early or emergency basis. Consequently, the woman's health required doctors to delay surgery until her medical condition stabilized. In addition to deflecting blame for causing any delays in completing the patient's diagnosis, the defendants also disputed the effects, if any, that the delays had on the woman's ultimate fate. They pointed out to the jury that because the woman was not a candidate for surgery during her 11 days of hospitalization due to her physical condition, any claimed delays in diagnosis did not cause her to suffer significant damages.

Finally, the defendant hospitals tried to pass liability along to the neurosurgeon and neurologist. They noted that on the second and third days of the woman's hospitalization, the neurosurgeon had scheduled consultations with the patient in favor of attempting any tests or procedures to prevent the woman's condition from worsening. Further, the defendants reminded the jury that even though the neurosurgeon had recommended angiogram testing for the possibility of an aneurysm, he had failed to follow-up to make certain that the neurologist performed the procedure in a timely fashion.

At the close of trial and during jury deliberations, the medical center system that operated the defendant hospitals settled with the plaintiff for $500,000 on behalf of the two hospitals. When the jury concluded its deliberations, it found the neurosurgeon to be 80% liable for the plaintiff's damages and the first hospital to be 20% liable. The jury did not find any negligence on behalf of the neurologist, the third hospital, or the medical center system. The court awarded the decedent's estate $5.6 million.

What this means to you: Due to the increase in obesity of the American population, the underlying factual scenario in this case is not uncommon.

"Health care facilities must be prepared to accommodate the special needs of the morbidly overweight patient," says Patti L. Ellis, RN, BSN, CPHRM, LHRM, corporate risk manager at Pediatrix-Obstetrix Medical Group in Sunrise, FL. Considering the comorbidities typically experienced by morbidly obese persons and the increased potential to forego routine medical care or follow-up testing, Ellis notes that it is not surprising to see these patients show up in the ED with a true medical emergency.

A hospital's ED, radiology/nuclear medicine department, operating room, and critical care areas, which are most likely to encounter unusually large patients without warning, are especially vulnerable to a situation similar to the one presented in this case, stresses Ellis. Therefore, as a patient safety and quality improvement initiative, Ellis suggests that these areas of the hospital perform a risk assessment of available equipment, diagnostic capabilities, personnel, and other resources to serve obese patients. Considering that the average CT scan table has a limited weight capacity, the facility may want to consider investing in new equipment.

"While the purchase of oversized patient care equipment can be costly, the price of defending a lawsuit can be higher," says Ellis.

Nevertheless, if your facility cannot accommodate morbidly obese patients and if the facility has elected to not invest in oversized equipment, Ellis emphasizes the importance of developing a patient care protocol for addressing these special needs. The risk manager should make note of the closest facility with an available oversize CT scanner, MRI, and other equipment. In the event that a patient has to be transferred to another facility that has the available service and equipment, the medical record should be well documented. The record should reflect the reason for the transfer, the acceptance by the receiving facility (including the name and title of the person accepting), consent from the patient or the patient's legally authorized representative, and the patient's condition at the time of transfer.

"As with any patient care protocol, be sure it's doable and approved by the hospital's medical staff," says Ellis.

Of course, the inability of the hospitals to accommodate the patient's large size in this case is not the only cause for concern. After all, even health care facilities lacking the resources to purchase the latest and greatest technology are able to adequately treat patients. In this case, Ellis questions why the neurosurgeon failed to follow-up with the neurologist to make sure the angiogram was performed in a timely fashion. Although health care practitioners may face shortcomings in the resources available to them, Ellis notes that there is no substitute for emphasizing the importance of good communication and documentation.

Reference

Antonio Riley, Individually, and as Administrator of the Estate of Elaine Riley v. Catholic Medical Center of Brooklyn and Queens Inc., Mary Immaculate Hospital, St. Joseph's Hospital, Richard Johnson, MD, and Richard Zupcak, MD, Queens County (NY) Supreme Court, Index No. 3439/97.