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$200,000 verdict granted in child's death
Failure to treat diarrhea alleged
News: A mother took her 4-year-old daughter to the emergency department with symptoms of gagging and watery diarrhea. The physician caring for the child determined that the child was not suffering from dehydration and provided a prescription for the child's nausea. The child's symptoms worsened. After the parent was told by the hospital to allow the medicine additional time to work, the child died. A verdict was entered against the hospital in the amount of $200,000.
Background: A 4-year-old child began experiencing water diarrhea and a gagging reflex. In response, the child's mother took the child to the emergency department. Upon arrival at the ED, the child came under the care of an emergency department physician. The ED physician determined that the child was not dehydrated and prescribed a drug typically used to relieve the symptoms of allergic reactions such as allergic rhinitis (runny nose and watery eyes caused by allergy to pollen, mold, or dust), allergic conjunctivitis (red, watery eyes caused by allergies), allergic skin reactions, and allergic reactions to blood or plasma products. The child was discharged with instructions for the mother to give her fluids.
The woman administered the drug to the child, but within a few hours the child's symptoms became worse. She became lethargic, had persistent diarrhea, and was unable to hold her head up to take a drink. Due to the increasing severity of the symptoms, the mother called the hospital and spoke to an ED nurse. While the contents of that conversation have been disputed, the mother alleges that the nurse told her to give the medicine additional time to work. Based on the information, the woman did not take her child to the hospital.
A few hours later, the child was found in her bed not breathing and frantic efforts were made to try and revive her. The child ultimately died.
For months, the child's death was considered a homicide by local police with the mother being the prime suspect. The police finally closed their case when an autopsy revealed that the child's death had been caused by dehydration secondary to body volume loss due to diarrheal enteritis or inflammation of the small intestine. The medical examiner also identified intoxication from promethazine as a significant contributing factor.
The child, her mother, father, and brother all had claims against the hospital. The plaintiffs also filed suit against the drug manufacturer, based on a higher concentration of the drug than was displayed on the label. The drug manufacturer ultimately was dismissed from the lawsuit as a court found that there was no solid evidence that the child's death was due to promethazine intoxication.
The claim against the hospital proceeded on the premise that the nurse should have instructed the child's mother to bring the child back when her symptoms were becoming worse. The hospital disputed this fact and put forth testimony that the nurse told the woman to bring the child back if the mother felt it was necessary. Both the physician and the hospital appeared to blame each other for the failure to provide adequate discharge instructions.
The jury returned a verdict in favor of the mother and the child's estate solely against the hospital in the amount of $200,000.
What this means to you: Hospitals should have a program to evaluate the competency of ED physicians to care for pediatric patients if the physician is not a pediatrician by specialty or there is no special pediatric emergency department. (Even then competency of all ED physicians periodically should be undertaken.) If the ED medical staff is provided to the hospital through contract, the contract should include the requirement that the contractor warrants that competencies of the most frequent types of conditions, or groups of signs and conditions, presenting to the ED are evaluated. Nursing staff should undergo a similar evaluation as well, especially if the ED does not have sufficient staff with pediatric education and experience.
It does not appear any blood work was drawn on this child to provide information regarding electrolytes and other information that might have pointed at different treatment or evaluation to avoid this unfortunate untoward outcome.
Dosages, signs and symptoms and evaluations in a pediatric patient are different than in adults. When staff members who are not experienced in pediatrics are accustomed to crossing over to care for pediatrics, a potential risk for medical errors and resultant untoward events increase. In this case, we do not know if the prescribed medication dose was appropriate for this child's weight and age or if it really were a concentrated dose from the manufacturer by mistake. However, if it were an inappropriate dose, the nurse should have recognized that problem and brought it to the physician's attention.
Risk management should work with administration and ED nursing staff to establish scripts for responses when patients call into the ED. Children might become more dehydrated or dehydrate more rapidly than an adult. Electrolyte imbalance can be more significant in a child as well. If the person responding to this mother had no pediatric experience or appreciation for this child's volume of fluid loss, the appropriate response was not forthcoming.
To prevent confusion regarding what a parent conveys and the advice given to a parent, the quality improvement/patient safety/risk prevention initiative of this hospital perhaps should consider taping/recording all ED calls in accordance with applicable state law. With today's electronic capabilities, the recordings could be kept indefinitely and randomly pulled for evaluation on many levels. The answering message for all incoming calls could advise that all calls are recorded for quality improvement purposes. Return calls to patients could be done on certain phones that record all calls.
The hospital should undertake a root cause analysis to determine how to prevent such cases from recurring and to identify the root "why" this happened. There is no indication in this scenario that a disclosure meeting was held with the family. This issue is one that risk management should facilitate, even if not included in the actual disclosure meeting. In addition, this case should be referred to peer review for further evaluation
Circuit Court of Indiana, Fifth Circuit, Jefferson County, Case No.: 39C01-0304-PL-182.