Legal Review & Commentary

Failure to monitor airway leads to Maryland death

By Jan J. Gorrie, Esq., and Blake J. Delaney, Summer Associate
Buchanan Ingersoll Professional Corp., Tampa, FL

News: A post-kidney transplant patient was admitted to a hospital with urosepsis and was placed in the intensive care unit. He was intubated; but when his airway became obstructed, efforts to correct the situation were unsuccessful, and he died. The case settled for $800,000.

Background: The 71-year-old male had undergone a successful kidney transplant. However, when he began suffering from urosepsis, a common side effect, he was readmitted to the hospital and placed in the intensive care unit for monitoring. He was intubated with a breathing tube to address respiratory distress and subsequent respiratory failure. When the nursing staff repositioned the patient to deliver care, his breathing tube became dislodged and blocked his airway. The nursing staff were unable to reposition it in a timely fashion, and the patient suffocated. The decedent’s family brought suit against the hospital for the negligent care and treatment by the staff. In the early stages of the suit, the hospital settled for $800,000.

What this means to you: "This case calls for a root-cause analysis," states Leilani Kicklighter, RN, ARM, MBA, CPHRM, director, risk management services, Miami (FL) Jewish Home and Hospital for the Aged and past president of the American Society for Healthcare Risk Management. "There are far too many unresolved issues that if left unresolved could lead to further untoward incidents."

The first line of questioning and focus is directed at the patient’s endotrachial tube. "Was there a mechanical defect or human error in the operation or placement of the tube? This should be the risk manager’s initial level of inquiry because such tubes are generally designed to allow for routine and necessary turning and repositioning of the patient. Respiratory patients must be turned to avoid pressure sores among other reasons, and so equipment used to care for such patients must be designed to accommodate the clinical need for repositioning. Nothing indicates that there was a defect in the tube balloon, and so the focus would turn to staff training, education and knowledge of placement and securing of endotrachial tubes as well as turning the patient once the tube is in place would need to be conducted," notes Kicklighter.

Once the tube is addressed, the second level of review is the timing and response of the emergency response team. "The initial inquiry in this regard would be whether the ICU staff was aware of the patient’s respiratory distress and the emergency ramifications. If the ICU staff were not aware of the fact that the patient was distressed, they may not have sounded the alarm. Alternatively, if the emergency response was called, it appears from the outcome in the case that their response time may have been lacking," adds Kicklighter.

"When things happen that should not have happened under normal circumstances and seemingly error upon error occurs, root-cause analysis and early resolution/settlement should be considered," concludes Kicklighter.


Jonathan Schochor and Kerry D. Staton with Schochor, Federico, and Staton, Baltimore, attorneys for the plaintiffs.