News: A 2-year-old girl died after her stomach ruptured from a recurring and treatable symptom. The girl had stomach issues in July 2009. After being sent to a second hospital, an examination of the gastrointestinal tract revealed the girl suffered from gastric volvulus, which can cause the stomach to twist on its axis. The condition naturally subsided, and the final diagnosis was gastroparesis, a condition that causes food not to properly pass through the stomach. The hospital staff released the patient the next day without following up on the girl’s stomach, providing special care instructions, or informing the parents that surgery could prevent recurrence. The Discharge Summary that went to the family’s primary pediatrician noted the stomach had fallen out of position. During two follow-up visits, the primary pediatrician treated the girl for constipation, told the parents the child didn’t need a specialist, and told them to call the office if the condition worsened. On Oct. 25, 2009, the girl was exhibiting the same symptoms, which prompted the parents to call 911. They also called their pediatrician, who suggested the child didn’t need to go to the emergency department (ED) but rather should stay home and be observed. The parents called off the ambulance. The next day, the girl’s condition worsened. She was rushed to the ED, where she was pronounced dead two hours later. The cause of death was a rupture due to her stomach being out of place. The parents sued their primary pediatrician and the hospital where he worked, as well as the second hospital and its staff who failed to inform the parents of the need for surgery, perform the surgery, or complete the pre-surgery tests. Both hospitals maintained throughout the trial that the girl received proper medical treatment and this was a “one-in-a-million” occurrence. The jury found both hospitals negligent and responsible for the conduct of their staff members, including the pediatric surgeon and pediatrician. It awarded $6.25 million to the parents.

Background: In July 2009, a 2-year-old appeared to be nauseated. Her parents took her to a hospital, where she underwent an X-ray by recommendation of a physician who believed her stomach had distended. The X-ray revealed that her stomach was out of place, which is a form of gastric volvulus, and she was transferred to a second hospital for further tests. Further tests ruled out many possible causes, but a review of the gastrointestinal tract results confirmed the girl’s stomach was out of place. The reviewing physician called the findings “critical,” believed surgery could be necessary to hold the stomach in place, and consulted with the hospital’s pediatric surgeon. The pediatric surgeon was unsure if the 2-year-old should be operated on and ordered a CT scan. The pediatric surgeon and treating physician conferred about the upcoming CT scan, but the pain and other symptoms the girl was experiencing had subsided. The treating physician gave the girl a physical examination and determined the cause of the symptoms was gastroparesis. The treating physician placed her on clear liquids and sent her to another room for observation. After seeing that the nutritional therapy was improving the girl’s condition, she was released from the hospital without receiving a CT scan or the surgery. The girl’s Discharge Summary noted that the “upper GI suggested organ axial rotation of stomach and small bowel malrotation” but concluded the girl was experiencing gastroparesis as the final diagnosis. Aside from being told to follow up with their pediatrician, the girl’s parents later alleged that they were not given special discharge instructions regarding the possibility their daughter’s stomach could “twist” again or that surgery could correct the condition.

The girl followed up with her primary pediatrician twice in the following months. Her primary pediatrician treated her for the gastroparesis and never mentioned anything to her parents regarding the stomach being out of place, information which was in the Discharge Summary report the pediatrician is alleged to have received. When asked by the girl’s mother whether there was a need to see a specialist for the 2-year-old’s stomach condition, the pediatrician informed her there was no need but to call the office if her condition worsened.

On Oct. 25, 2009, the girl’s parents called 911 because she was exhibiting intense abdominal pain. The parents also called the girl’s primary pediatrician, who recommended that the parents not take her to the ED but observe her instead. The parents, who later said they were acting on their pediatrician’s advice, canceled the ambulance that was on its way.

The next day, while still at the family’s home, the girl was vomiting and unable to drink anything. Her parents called 911, and she was rushed to the ED. Just more than two hours after arriving, she was pronounced dead. An autopsy ruled the cause of death was her stomach twisting, which caused it to rupture.

The girl’s parents sued the second hospital and its staff. The lawsuit included the pediatric surgeon for not recommending surgery, her treating physician who released the girl without recommending or explaining the need for surgery, and the hospital for the acts of its employees and for not following protocol. They also named her primary pediatrician and the hospital where he worked for failing to be aware of the severity of the patient’s condition and for not recommending she see a specialist for the stomach abnormalities or go to the ED the day before the girl died.

The defendants maintained that they followed proper protocol and didn’t commit negligence or medical malpractice. The jury found the staffs of both hospitals acted negligently for not informing the parents that the surgery to correct the gastric volvulus could have prevented the stomach from twisting again. The jury awarded the parents $6.25 million in damages.

The damages breakdown was $3.7 million for wrongful death, $2.5 million for future loss of earnings and earning capacity, and $50,000 for pain and suffering. The pediatric surgeon was found 65% liable of the damages, the treating physician was found liable for 10% of the damages, and the hospital where these physicians were working was found liable for 5% of the damages. The family’s primary pediatrician was found liable for 20% of the damages.

What this means to you: This case displays the need for physicians to consult, consider, and acknowledge the suggestions and recommendations of other physicians in general, and especially at the hospitals where they work. In this situation, the pediatric surgeon knew the prior testing revealed “malrotation” of the stomach. The doctor who initially reviewed the findings of the test considered this “critical” and recommended surgery. However, the severity of the prior findings and recommendation of surgery by the reviewing physician were not conveyed in the report of the pediatric surgeon to the treating physician who released the girl.

When her symptoms subsided and a physical exam suggested the problem was gastroparesis, the physician likely felt comfortable releasing her without further inquiry. Yet, if the report by the pediatric surgeon emphasized the need for surgery as much as the report given to him did, the girl likely would not have been released without the completion of pre-surgery testing and an explanation to the parents regarding the possible necessity of surgery. Thorough reporting of all the physicians’ suggestions, following through on the suggestion for pre-surgery tests, or explaining the need for surgery to the girl’s parents would have served to shield the hospital from liability. All are based on communications with other physicians and the patient. A physician should take special care to accurately convey to the next physician all potentially relevant and known information and opinions, and the physicians should be equally as diligent in explaining those findings to their patients and their patients’ parents.

Another lesson is that a primary care physician should thoroughly examine the Discharge Summary by the physician at the hospital from which the patient came. Here, the Discharge Summary noted that the girl’s stomach had been out of position. However, her primary pediatrician didn’t recommend the girl seek further treatment, but he treated the child for constipation. Had the malrotation of the stomach been fresh in the primary physician’s mind, further treatment or consultation might have been recommended when the mother initially asked.

Lastly, a physician should call off emergency services only if he or she is certain it is the right decision. When a patient is being rushed to the hospital by ambulance for conditions similar to the ones a physician believes he or she has treated, that physician should not assume it is for the exact same condition. Preventing a patient from receiving care, which is later shown to be have been necessary, can clearly harm the patient and will rarely be perceived favorably by a jury.

Also, a physician shouldn’t prevent a patient from seeking aid from another physician, hospital, or emergency aid service without first conducting a physical examination. The parents halted the emergency services that could have saved her life, and they followed the suggestion of their pediatrician who likely assumed the condition was the same constipation issue that would pass. A physical exam or thorough review of the file would have revealed the malrotation of the stomach months prior. It likely would have led to the ambulance trip and the girl receiving life-saving aid. Physicians must be certain when preventing a patient from receiving emergency aid or care from another physician.

REFERENCE

  • Court of Common Pleas of Pennsylvania, Luzerne County. Case No. 11-09921 (May 20, 2015).