Legal Review & Commentary
Failure to recognize infection leads to sepsis and amputations, and $32 million settlement
By Damian D. Capozzola, Esq.
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
Angelina Gratiano, Esq.
News: After complaining of a fever and inability to put weight on her right leg, an 11-year-old female was taken to the emergency department of a local hospital. The child had an internal infection that was quickly spreading. After waiting more than 24 hours for antibiotics, the child went into septic shock, then cardiac arrest, and ultimately organ failure. Tragically, the child's arms and legs had to be amputated to save her life. The child's mother brought suit against the hospital and five doctors responsible for the child's care shortly after the child was released from the hospital. Before going to trial, the hospital made the decision to settle the case for $32 million. However, pursuant to the terms of the settlement, the hospital did not admit fault.
Background: During the day at school, the child hit her knee while playing, but bounced back quickly. However, the following day, the child developed a fever and was not able to stand on her right leg. Because the child did not often complain about pain, the mother decided to take her to the local hospital for emergency treatment. Upon arrival, the triage nurse noted that the child was running a fever of 100 degrees Fahrenheit. The child remained under observation of the hospital, yet no medications were prescribed even after the fever jumped to 104 degrees. Despite worsening leg pain and an elevated white blood cell count, the physicians still had not started treatment with antibiotics or any other medication.
More than 24 hours after arriving at the hospital, the hospital staff finally began administering antibiotics. However, the damage to the young girl's body already was irreversible. The child went into septic shock, which caused her blood pressure to decrease dramatically. Shortly thereafter, multiple organs were failing, and she was unable to breathe on her own. The child went into cardiac arrest but was stabilized.
During the following days, the young girl's limbs turned purple, as gangrene had developed in her arms and legs. The physicians made the difficult but necessary decision to amputate all four of the girl's limbs to keep her alive. For the next two weeks, the girl remained in a medically induced coma. Her mother was unsure whether she would survive. The young girl pulled through after spending two months in the hospital and then months in rehabilitation. Eventually the child learned how to walk around with her prosthetic legs and do basic tasks such as dressing herself.
Her mother brought suit against the hospital and the five treating physicians for medical malpractice and family damages after doing research on sepsis and realizing how crucial it was for the hospital to have acted quickly in treating her daughter. The mother claimed that the hospital failed to recognize that the child's vital signs and white blood cell count were consistent with sepsis and failed to provide the child with broad-spectrum antibiotic coverage within the first critical hours of the child's admission to the emergency department. Additionally, the hospital failed to admit the child to the pediatric intensive care unit for immediate care and treatment. The mother's complaint stated that as a proximate result of the hospital's multiple omissions, the child developed septic shock resulting in the amputation of her four limbs. Prior to commencing trial, the hospital agreed to settle the case for $32 million while denying culpability for the child's condition.
What this means to you: It is estimated that more than 750,000 people die each year from sepsis. Generally, the elderly population or persons with weakened or compromised immune systems are most vulnerable to sepsis. The quickly spreading infection is particularly dangerous because of how the body reacts to the infections. Chemicals are released into the bloodstream to fight the infection, which then causes systemic inflammation and eventually life-threatening damage to various organ systems. As sepsis worsens and further develops into septic shock, blood pressure significantly decreases, which often leads to the need for amputations, or death. It is always important to be alert for complications arising from sepsis.
Because the case did not proceed to trial, it remains to be seen what standards the hospital in question had regarding pediatric treatment for symptoms of sepsis. Many questions remain as to why the hospital chose to delay treatment for the broad-spectrum antibiotic treatment or even any standard course of antibiotic at all. What is most obvious is a repeated lack of action by the hospital staff to intervene.
The necessity for a standard triage protocol is crucial to the patient's outcome, and the hospital's ability to provide standard patient care cannot be overstated. A standard triage protocol is especially important for children, as their immune systems are more vulnerable and susceptible to infections. In this case, the plaintiff's medical experts alleged that child developed sepsis when she fell down at school prior to her hospitalization. Although there were no visible signs of damage or injury to the child's right leg, blood accumulated internally around the tissue damaged by the fall. While there were no external signs present when the child was admitted to the emergency department, the hospital staff should have followed some sort of procedure to determine if she had an infection and planned to treat it immediately. When the child entered the emergency department, she presented with a fever and an inability to put weight on her right leg. This presentation should have been enough for the hospital staff to immediately investigate an infection. Furthermore, despite laboratory results indicating an elevated white blood cell count, the hospital again neglected to provide the child with antibiotics to control the spreading infection. Had the hospital used an established pediatric triage protocol, and followed through with it, the child very well might have kept most, if not all, of her limbs.
Additionally, hospitals must be willing to forego diagnosing a patient based on one symptom in favor of a identifying and evaluating all the symptoms a patient presents with collectively and simultaneously. Too often medical professionals "follow the garden path" based on a primary symptom and overlook other symptoms or circumstances that might differentiate a given case from others with similar initial primary presentations. In this case, the child was admitted to the hospital with a low-grade fever, which likely did not warrant immediate treatment in and of itself. However, had the hospital staff considered the totality of the symptoms as presented, namely the fever, the recent fall, pain on ambulation, and an elevated white blood cell count, this should have raised serious concerns for the physician regarding sepsis. By neglecting to consider all the symptoms, physicians can misdiagnose a very serious condition that might lead to fatal results.
The Centers for Medicare and Medicaid Services as well as The Joint Commission expect that hospitals will comply with basic sepsis screening requirements for all patients coming in to their emergency departments. A screening tool is usually used to help emergency department staff quickly identify sepsis and severe sepsis. Elevated white blood cell counts accompanied by fever are two signs of sepsis that would trigger moving further along the tool's algorithm. A recent soft tissue injury must be considered as a source of infection, especially in the absence of upper respiratory symptoms, which is the most common source of sepsis in children. Even though the child's temperature was below 101 degrees Fahrenheit, which is usually the level indicative of sepsis, the recent knee injury should have been considered a significant part of the diagnostic screening. A simple CT scan of the child's knee would have shown the soft tissue swelling and fluid accumulation, the breeding ground for unwelcome bacteria. Intravenous antibiotics and fluids would have prevented the progression to severe sepsis and ultimately, septic shock that devastated this young child's frail body.
It is said that, in this case, laboratory results and scans were not ordered soon enough to determine the source of the problem in an efficient and timely manner. Instead, laboratory results were ordered, and then the patient and mother waited hours. Then the physician reviewed the results. More time passed. Eventually more than 24 hours passed before a decision was made to provide the child with antibiotics. Had multiple possibilities been considered simultaneously, less time would have been wasted waiting prior to diagnosing the patient and administering treatment. All in all, although the settlement amount was substantial, by settling the hospital minimized the bad publicity surrounding the incident and avoided even greater potential liability.
- Case No. 2013P005509(Cook County Circuit Court, Cook County, IL). Oct. 10, 2013.