Legal Review & Commentary
Failed coiling procedure and inadequate follow-up leads to partial paralysis, $23 million verdict
By Radha V. Bachman, Esq.
Buchanan Ingersoll & Rooney
Barbara Reding, RN, LHCRM, PLNC
Central Florida Health Alliance
News: A 34-year-old nursing student complaining of headaches presented at a local university hospital. Diagnostic testing showed a small aneurysm. During a procedure intended to repair the aneurysm, the woman's brain was pierced. As a result of the inadequately performed procedure and adequate follow-up, the woman is paralyzed on her left side and is in constant pain. A jury found the hospital 100% liable and awarded the plaintiff $17.6 million in damages. A total award of $23.4 million was handed down.
Background: A young mother of four children presented to the hospital complaining of chronic headaches. Tests found a non-bleeding aneurysm in her brain, and a neurosurgeon performed surgery in which coils were inserted into the aneurysm. Counsel for the plaintiff's alleged that during the procedure, the woman's brain was nicked.
Following the procedure, the woman, who had been put on a blood-thinning medication called Heparin, displayed symptoms consistent with a postoperative stroke. The lawsuit filed by the plaintiff contended that a nurse observed the symptoms, but nonetheless continued the medication. By the time doctors discovered the problem following a longer-than-reasonable delay, the woman's brain was filled with blood. Significant brain damage had occurred.
The woman underwent 10 surgical procedures. In one of those procedures, skin from the woman's ankle was moved to the woman's skull, which left her with an ankle tattoo on her head. Additionally, the woman developed Methicillin-resistant Staphylococcus aureus (MRSA), became septic and contracted pneumonia while in the hospital. Since her initial presentation to the hospital, the woman has been hospitalized more than 30 times. Due to her condition, the woman's children have been forced to separate and live in different homes.
The woman uses a wheelchair and is paralyzed on her left side. She suffers incontinence, bladder problems, and urinary tract infections. The woman is unable to work. The woman sued the hospital and the nurse staffing company. The woman's children sought damages for loss of parental guidance, and her husband sought an award for loss of consortium.
A jury in the case returned a verdict solely against the hospital in the amount of $23.6 million, allocating $17.6 million to the woman, $1 million to each of the woman's children, and $1.8 million to the woman's husband.
What this means to you: This case exemplifies one of the many high-risk situations that encompass a healthcare risk management program. From the viewpoint of provision of healthcare services, emergency services and surgery, anesthesia, and recovery are but a few of the high risk areas in healthcare today. From a litigation standpoint, the risk also begins with the patient's age and health status. We often expect it is the older patient facing surgical intervention who has the potential to put the organization at greater risk. Consider, however, a 34-year-old female, in apparent good health, mother of four, and a student. Should anything "go wrong" during her hospital course, the healthcare providers circumstantially could be faced with actual damages involving life expectancy dollars, loss of work, loss of activities of daily living functions, and loss of consortium, not to mention punitive damages in the event of a finding of medical malpractice and/or negligence.
It is assumed in this case that an appropriate and properly executed informed consent was obtained prior to the coiling procedure. It is also assumed, by virtue of the definition and regulatory requirements regarding informed consent, the risks, benefits, and alternatives related to this procedure were fully disclosed to and discussed with the patient by the surgeon(s) who would be performing the procedure. The benefits of intervention for a non-bleeding brain aneurysm in a young adult are obvious. The alternatives might include medical/pharmaceutical management and consistent monitoring. The risks would likely include (as most standard informed consent documents today demonstrate) such terms as bleeding, additional unplanned surgical intervention, administration of blood or blood products, rupture, death and more. It is further assumed that the patient was provided the opportunity to ask questions and have her questions answered.
Consent documentation, especially the type that is specific to the designated procedure, aids in the defense of a case and defining whether the occurrence is a reportable event. It is prudent for risk managers to work with their organization to establish consent policies and procedures in accordance with state law, consent definition, and components. Risk managers must work with clinical educators to develop education programs in obtaining and executing informed consent with good documentation of same, to ensure compliance with consent practices.
Informed consent does not stand alone in defending a surgical procedure "gone wrong." The possibility of inadvertently penetrating an area of the brain during the coiling procedure might have been an identified risk in the informed consent process. However, inadequate postoperative monitoring, symptom communication and management, and delayed recognition of presenting symptoms and diagnosis led to failure to rescue this wife and mother before permanent brain and other damage had occurred. This inadequacy raises the ongoing clinical issues of assessment, re-assessment, reporting, communicating, and intervention. Monitoring and interpreting changes in mental and physiological status following the procedure would be critical.
At the heart of this case was the failure to timely diagnose bleeding in the brain and recognize and manage the symptoms associated with it. The plaintiff's attorneys alleged "the nurse observed the symptoms" consistent with a postoperative stroke, and the physician continued the heparin orders. Helping the organization understand the importance of assessment, documentation, and hand-off communication, and the need to reinforce and monitor clinical practices, is yet another aspect of the risk manager's role.
While heparin is not the drug of choice for stroke patients, the administration of heparin might have been considered appropriate for some circumstances in a patient presenting with an ischemic (blockage) stroke. It would have been detrimental for a patient presenting with a hemorrhagic (bleeding) stroke. The plaintiff and defense attorneys' expert witnesses most likely argued the positive and negative effects of the continued heparin administration; unfortunately, by the time of trial, this would not and could not change the outcome for the patient. The damage had been done.
The plaintiff and defense attorneys also might have argued the competency of the surgeon(s) through information obtained via the hospital's peer review and Ongoing Physician Performance Evaluation (OPPE) processes as defined by The Joint Commission. While some of this information is delicately protected, data might be provided to support or refute physician competency. Again, it is important that the risk manager support education programs and requirements for consistent and continuous excellence in safe patient care. Helping others understand why compliance is important is key.
With a tragic outcome such as the one for this patient, an organization must conduct a thorough and respectful analysis of the event. The Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) require that "the hospital must measure, analyze, and track quality indicators, including adverse patient events" (CMS 482.21) and "conduct thorough and credible root cause analyses" (TJC LD.04.04.05).
Whatever the facts presented at trial, the jury clearly held the hospital solely responsible for the physicians and surgeons it credentials, the nurses it employs, and the unfortunate outcome for the patient. What does this mean to us? We must be and remain diligent in our efforts to train, lead, and hold accountable all patient safety system practices and procedures. This includes assessment, re-assessment, and communication. We must take the "lessons learned," share them with staff, and clearly identify and implement practices of prevention for the future.
Florida Circuit Court, Eighth Judicial Circuit, Alachua County, Case No. 01-2008-CA-006413 K