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By Damian D. Capozzola, Esq.
The Law Offices of Damian D. Capozzola
Jamie Terrence, RN
President and Founder, Healthcare Risk Services
Former Director of Risk Management Services (2004-2013)
California Hospital Medical Center
Elena N. Sandell, JD
UCLA School of Law, 2018
News: A jury found a hospital and team of physicians negligent for a patient’s death shortly after giving birth, caused by significant blood loss due to a condition known by her physicians.
The condition created a high risk during delivery and should have been planned for accordingly to minimize the chances of life-threatening complications. However, the physicians who had followed the woman throughout the pregnancy and who were aware of the potential life-threatening complications failed to adequately prepare a plan for the scheduled cesarean section.
The patient’s surviving husband filed a lawsuit on behalf of himself and their four children, alleging that the physicians and hospital’s actions constituted medical malpractice. The jury agreed and awarded the patient’s family a total of $24.5 million.
Background: From the initial stages of her pregnancy, the patient, a 34-year-old woman, was known to have a condition known as placenta previa and suspected to have placenta accreta. Placenta previa is a condition where the placenta attaches low in the uterus and can completely cover the cervix. Placenta accreta is a condition where the placenta attaches too deep into the uterine wall, which can lead to severe and uncontrolled bleeding during delivery. Both conditions are potentially life-threatening, requiring extreme caution and heightened attention. Patients suffering from either condition must be monitored closely throughout the pregnancy, and routine delivery practices should be adjusted to ensure that in the case of severe bleeding, physicians and staff are ready to immediately intervene.
The patient’s physicians, who subsequently performed the cesarean section, were aware of the conditions affecting the woman during the early stages of her pregnancy and prenatal care. However, the patient claimed that the physicians and hospital did not adequately prepare for the potential complications caused by the condition.
On July 21, 2015, the patient entered the hospital for the scheduled cesarean section. The procedure was scheduled to take place at 10 a.m. but was delayed over 14 hours. The procedure finally took place at midnight on July 22 and was not performed on an emergency basis. During the procedure, the patient’s placenta accreta caused substantial bleeding: The patient lost approximately 10 liters of blood and went into cardiogenic and pulmonary shock associated with severe hypoxia.
Moments after delivery, the patient was put on full ventilator support and a selective embolization of the left uterine artery was performed. The patient was transported to an operating room in an attempt to control the bleeding through an exploratory surgery. Despite these efforts, the patient was pronounced dead a few hours later as a result of multiorgan failure from hemorrhagic shock. Examinations confirmed that the low cervical cesarean section and placenta accreta caused the massive bleeding.
The patient’s husband filed suit against the hospital and the treating physicians on behalf of himself and their four minor children. The complaint sought compensation for each individual’s loss of support and services, and mental pain and suffering. The jury agreed that the hospital and physicians failed to provide care within the applicable standard, and awarded $3.7 million to the patient’s husband, $4.9 million to each of the three eldest children, and $6.1 million to the youngest child, for a total award of $24.5 million.
What this means to you: The primary lesson in this case is for physicians and care providers to take into account a patient’s specific medical history and medical conditions when determining the proper level of care and appropriate treatment for the patient. If a healthcare provider is aware of a relevant condition that may affect the course of treatment, then it may constitute medical malpractice to disregard that condition and otherwise proceed normally. In this case, the patient’s surviving family successfully argued that the physicians were aware of her two existing medical conditions, that those conditions posed a threat, and that the physicians did not take the conditions into account when planning and treating the patient.
These conditions are not novel. They are well-known and well-researched, as they relate to a nationwide problem of maternal mortality, which has been consistently increasing since the 1970s and has placed the country’s healthcare system under scrutiny. Placenta previa is a serious condition that can be seen on routine ultrasounds. Once that diagnosis is confirmed by a physician or radiologist, a vaginal delivery cannot take place safely in most cases and physicians must inform their patients that a cesarean delivery is the safest option. Placenta accreta, though less common, is a far more dangerous condition that usually requires not only delivery via cesarean section, but removal of the entire uterus via a hysterectomy as well due to the uterine tissue in the area of the accreta. This can present an emotional decision for a woman to make, especially if she was planning to have additional children. Physicians must allow a patient time to process the information about her condition and be well informed about what to expect.
Another important lesson from this case is that physicians and care providers must recognize when circumstances exist or change such that emergent action and care are required. In this case, the physicians delayed and performed a standard cesarean section without the additional care and security offered by emergency precautions and procedures. During delivery, if contractions are noted on the fetal monitor, the staff must proceed with the delivery on an emergent basis. Intravenous medications to stop any contractions should be given. An obstetrical hemorrhage should be anticipated during and after delivery for both conditions, and a sufficient supply of red cells, plasma, and other blood products must be available for immediate transfusion. The patient should be transferred to a high acuity postpartum unit with emergency equipment readily available and a well-trained staff with a low nurse/patient ratio.
As successfully argued by the patient’s surviving family, the injuries that led to the death of the 34-year-old mother of four could have been prevented with adequate medical attention and preparation. Instead, after an initial diagnosis, the physicians failed to prepare and follow up with additional testing — which ultimately led to devastating consequences.
In particular, the patient’s family alleged that following the initial visit, where placenta previa was diagnosed and where placenta accreta was suspected, physicians should have followed up with additional testing to confirm the diagnosis and should have monitored the pregnancy with increased attention, closely assessing the risks associated with delivery and changing the necessary circumstances of the delivery as needed. Specifically, physicians should have followed recommendations and performed a transvaginal ultrasound and obtained an MRI to confirm whether placenta accreta was present. Additionally, given the two conditions, the physicians should have performed a hysterectomy prior to the onset of uncontrolled bleeding. In fact, while a hysterectomy was performed on the patient during the surgery, the timing was not sufficiently prompt, and this delayed intervention caused the patient’s extreme blood loss.
When presented with these facts and the applicable standards of care, the jury found the that the physicians were negligent and breached the required standard of care by planning to perform a routine procedure without taking into account the specific factors that created life-threatening risks for the patient. The follow-up procedures should have been performed at the time the condition was first suspected. Furthermore, the delivery and possible complications should have been planned for and the possibility of a hysterectomy in order to preventively control internal bleeding should have been taken into account.
The complaint also raised claims against the hospital where the patient received her care. These claims were brought under theories of agency and vicarious liability and alleged that the hospital should be held liable for the negligence of its employees or agents who were acting within the scope of their employment or agency at the time of the incidents. Employer hospitals often are attributed such derivative liability as a result of the actions of their agents and employees.
Finally, a procedural, legal issue can be learned from this case as well: Prior to trial, the defendant physicians and hospitals conceded that their actions constituted malpractice, and admitted liability. Such an admission can serve multiple functions in the absence of a complete settlement between the parties, including by making the defendant care providers appear reasonable to a jury by acknowledging their mistakes and accepting responsibility. Additionally, this process greatly expedites any trial, which reduces the amount of time, effort, and attorneys’ fees that must be spent in a futile attempt to defend a hopeless case. Considerations regarding stipulations concerning liability must be carefully weighed by care providers and their counsel, but may prove to be useful in litigation.
Decided on April 18, 2018, Florida State Court, Case No. CACE18001011.
Financial Disclosure: Author Greg Freeman, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Leslie Coplin, and Nurse Planner Maureen Archambault report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Consulting Editor Arnold Mackles, MD, MBA, LHRM, discloses that he is an author and advisory board member for The Sullivan Group and that he is owner, stockholder, presenter, author, and consultant for Innovative Healthcare Compliance Group.