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By Mark K. Delegal, Esq., and Jan Gorrie, Esq.
Pennington, Moore, Wilkinson, Bell & Dunbar, PA
News: After repeated visits to her obstetrician and the emergency room, a high-risk pregnant woman underwent an emergency cesarean. Prior to and during the delivery, she was not given appropriate care. She developed multiple pulmonary emboli and adult respiratory distress syndrome. She died 11 days after delivering a healthy baby girl. A Philadelphia jury returned a $1.1 million verdict against the hospital and physicians.
Background: The 26-year-old woman, in her 38th week of pregnancy, was diagnosed with high blood pressure by her obstetrician. She had been classified as high risk because she was extremely obese, weighing close to 350 pounds. Her mother had died of preeclampsia, also known as pregnancy-induced hypertension (PIH), while giving birth.
On Dec. 15, 1993, her original due date, the expectant mother went for a routine obstetrics visit. She had all three major symptoms of PIH — hypertension, swelling, and protein in her urine. The OB referred her to a teaching hospital for follow-up tests, including a nonstress test and biophysical profile. At the hospital, her blood pressure was found to be within normal limits, but she was diagnosed with preeclampsia by the hospital’s attending resident physician. She was sent home with a prescription for iron supplements and told to return for a follow-up office visit Dec. 22 if she did not go into labor before them. Neither her obstetrician nor any one at the hospital advised her of the risks associated with her condition.
On Dec. 22, the expectant mother told her obstetrician she was having irregular contractions. Though her cervix was dilated 1 cm and 50% effaced, the doctor arranged for her to be induced the following day. Her obstetrician also ordered a nonstress test and urine dipstick to be done at the hospital. Notwithstanding her elevated blood pressure and abnormal dipstick results, the hospital staff neither admitted her nor questioned the obstetrician’s instructions to delay inducement until the next day. Hospital staff also did not apprise her of the potential dangers due to preeclampsia.
The next day, instead of being admitted to the labor and delivery room, which was provided for in the hospital’s protocols for high-risk pregnant women, she was kept in a waiting room until 9 p.m. During this period, her condition was not monitored, her vital signs were not taken, and routine laboratory studies were not conducted. According to the first nursing note taken on Dec. 23 at 9 p.m., the patient’s blood pressure was elevated and she complained of headaches. Despite the resident physician and nursing assessments showing consistently elevated blood pressure readings from that point forward, she was not placed on blood pressure-lowering drugs, essential for controlling her condition, until 8:40 the following morning — nearly 24 hours after her arrival at the hospital.
At about 11:30 a.m. on Dec. 24, the patient was rushed to the operating room for an emergency cesarean section and her baby was delivered. The baby girl was born healthy. The medical team neither initiated heparin therapy nor placed antithrombin hoses on the patient that might have lowered her blood pressure.
Failure to take such precautions created blood clots in her lungs and the onset of pulmonary edema. The patient briefly regained consciousness following the cesarean section, but her condition soon deteriorated. She was placed on a ventilator to assist with breathing and was transferred to the intensive care unit.
The plaintiffs claimed that her consulting and attending physicians failed to timely diagnose and appropriately treat her multiple pulmonary emboli and again failed to order deep-vein thrombosis prophylaxis in a timely fashion. Her endotrachecheal tube was also consistently malpositioned. She developed adult respiratory distress syndrome and died 11 days later.
The plaintiff’s estate brought suit against the hospital and physicians for negligence. The plaintiff’s expert linked the development of the pulmonary emboli to the failure to treat her preeclampsia in an expedient manner. Prior to the seven-day trial’s conclusion, several of the physicians, including the obstetrician who provided prenatal care and attended the delivery, settled for an undisclosed amount. The trial proceeded against the hospital and the jury ultimately rendered a $1.1 million verdict against the hospital and physicians; $200,000 was attributable to the wrongful death action and $900,000 was for the surviving child. The hospital was found 25% liable and the attending physician 75% liable. Of the hospital’s share, the jury found the nurses 10% responsible under vicarious liability and the hospital itself 15% responsible under a theory of corporate negligence.
In this jurisdiction, there can be a finding of corporate liability if the hospital fails to uphold any one of the following duties: a) to use reasonable care in the maintenance of safe and adequate facilities; b) to select and retain only competent physicians; c) to oversee all persons who practice medicine within its walls as to patient care; and d) to formulate, adopt, and enforce adequate rules and policies to ensure quality care for the patients. The hospital was specifically found not to have provided sufficient oversight of all persons who practiced medicine at the facility because the staff nurses and residents did not recognize and/or report the patient’s abnormal conditions in a timely fashion. The failure by staff to report changes in the patient’s condition and/or question the physician orders that were not made in accordance with those changes were found to have been indicative of the hospital’s negligence. In its defense, the hospital merely averred that the finding of corporate liability was not warranted under the law or the evidence.
What this means to you: "Protocols and procedures can be a risk manager’s best friend, but can become their worst enemy if not adhered to and followed," states Cliff Rapp, vice president of risk management at FPIC Insurance Group in Tallahassee, FL. Protocols and procedures can be great tools for guiding health care practitioners on patient care, particularly when facilities have to do more with less staff. However, if something goes awry, plaintiffs’ lawyers will go to great lengths to see if you have broken your own rules. This case presents an example of how damaging the failure to employ one’s own policies, procedures, and protocols can be.
"When the patient first presented to the hospital on Dec. 15th, she clearly met criteria for being not only high risk’ in terms of her obstetrical profile, but also at risk’ given all clinical indices. The patient was at term, exhibited pregnancy-induced hypertension, and other symptomatology that was classically preeclamptic. She clearly needed to be admitted and delivered; and had the established protocols been followed, this would have occurred," Rapp says.
"It is difficult to imagine that any defense offered could overcome the fact that once the patient was finally admitted to the hospital seven days later than one might have expected, she essentially went untreated and unmonitored for another 14 hours. In direct conflict with established policies and procedures, the patient languished in the wrong waiting room. Once an assessment was finally made, it is clear that the patient’s condition had progressed to the fulminate stage and her blood pressure was out of control. Unfortunately, the delay in the delivery, without any antihypertensive treatment whatsoever, was allowed to occur despite the established treatment protocols begging a different course of action. This eventually led to the development of pulmonary edema, which further compromised the situation," notes Rapp.
"What may have otherwise been a defensible case became indefensible. Any potential causation defense relative to the wrongful death aspect of the case was forfeited by the failure to initiate prophylaxis for the prevention of the pulmonary emboli. Not only did the jury apportion liability against the physicians and nurses, but also against the hospital for failing to provide adequate oversight to those health care providers involved in the patient’s labor and delivery. The hospital’s very protocols were, no doubt, used to reach that decision," he adds.
"Management of labor is the most common focal point in obstetrical claims. Delay in diagnosis and treatment of preeclampsia is a leading factor necessitating settlement of such cases. Settlement is often advised because the protocols designed to avoid unnecessary delays in the case of known high-risk women are simply not followed, and in some instances, such as this case, seemingly ignored. Evaluation and treatment of high-risk obstetrical patients must, at a minimum, be in accordance with established protocols. Protocols are designed for that very purpose. If the protocols are not followed and no clear reason can be provided for such deviation, and an adverse result occurs, watch out for the plaintiff’s attorney," concludes Rapp.
• Jackie P. Whittington, administratrix of the estate of Claudette E. Milton, deceased, and Kadijah Nicole Woods, individually, in her own right vs. Episcopal Hospital, et al. No. 1858, Philadelphia County (PA) court of Common Pleas.