Legal Review & Commentary

Jury awards patient $7.6 million in case of permanent spinal cord injury

By Radha V. Bachman, Esq., LHRM

Buchanan Ingersoll & Rooney

Tampa, FL

Leilani Kicklighter, RN, ARM, MBA, CHSP, CPHRM, LHRM

The Kicklighter Group

Tamarac, FL

News: In 2003, a 14-year-old girl went to the emergency department (ED) with complaints of weakness in her legs. The radiology department performed an MRI, but it failed to diagnose an abnormal mass on her spine. When the mass bled four years later, the patient suffered permanent spinal damage. At age 18, the woman was a paraplegic. The jury awarded the woman a total of $7.6 million dollars in damages.

Background: In mid-December 2003, a young woman woke up one morning and immediately had weakness and numbness in her legs. After first visiting her pediatrician, the woman's parents sought care for her in the ED of a local medical center. The woman was admitted to the hospital, and physicians ordered a magnetic resonance imaging scan (MRI). The radiology department read the scan as normal; however, the MRI showed an abnormal mass in her thoracic spine. She was diagnosed with and treated for Guillain Barre Syndrome, an autoimmune disorder that can cause ascending paralysis. Exactly what triggers Guillain Barre Syndrome is unknown. The syndrome may occur at any age, but it is most common in people of both sexes between ages 30 and 50. The woman was discharged from the hospital on Christmas Day.

The young woman returned to high school and eventually graduated. The summer after graduation, she became pregnant. In February 2008, four years after the initial incident, the patient began to experience the same symptoms. The woman was taken to another hospital. Another MRI was performed, while taking into account the Guillain Barre Syndrome. This time, treating physicians discovered an arteriovenous malformation in her thoracic spine. The patient underwent surgery to remove the mass; however, it already had bled into her spinal cavity. The bleeding resulted in a permanent spinal cord injury. At 18 years old, the woman was a T4 paraplegic, so she was unable to move her body from the chest down. At the time of the verdict, the woman had a 3-year-old son, and she requires special medical care and an attendant for the rest of her life.

The woman filed a complaint against the medical center and claimed the hospital's failure to diagnose the mass resulted in her paralysis. In court, the woman's expert testified that the mass was visible on the MRI from 2003 and should have been diagnosed by the radiologist at that time. The expert claimed that if the radiologist had detected the tumor, further studies would have led to proper treatment and the removal of the mass. Additional testimony was offered regarding the fact that the radiology department at the hospital had varied from its standard protocol for performing this kind of study, which would have included views in two planes: sagittal and axial.

The medical center denied any negligence in the case and claimed the medical care provided was appropriate. Furthermore, the hospital testified that both views had not been obtained because the patient was uncomfortable in the machine. The evidence showed, however, that she was seated and had no difficulty with the study. The hospital's expert testified that because the mass was subtle, the hospital's failure to diagnose was within the standard of care owed to the patient at that time. The hospital also claimed that the woman's parents were at fault since they followed up with the girl's pediatrician instead of a trained neurologist.

After three days of deliberation, the jury found that the medical center was negligent in their care for the woman in 2003. The jury awarded the woman $6.4 million for lost wages and ongoing medical care, including a medical attendant to care for her. Additionally, the jury awarded the woman $1.2 million for pain and suffering; however, due to state medical injury laws, her non-economic damages will be reduced to $250,000. The total verdict of $7.6 million is believed to be one of the largest medical malpractice verdicts in the county's history.

What this means to you: This situation involves an unfortunate, preventable missed diagnosis and, therefore, a misdiagnosis that resulted in a devastating untoward outcome. There are a myriad of risk management, patient safety, standard of care, and patient care issues raised by this situation.

In such events, the first notice is often the notice of intent to sue or service of the actual Summons and Complaint, depending on the laws where the event occurred. In this case, it was four years; this lapse of time means personnel, physicians, standards of care, and electronic aspects might have changed, and memories might not be as sharp. These circumstances create challenges for the risk manager in terms of fact-finding and in regard to loss control activities. Therefore, when events such as this one occur, facilities should take measures to document the events and involved personnel.

The risk management activities or actions that should be taken to investigate the events that lead to an untoward outcome and the determination and implementation of loss control action are not linear, or one after another. One of the skills of a risk manager is multi-tasking and the ability to prioritize. An event such as this one can be particularly challenging.

Another challenge is that the evolution of electronic equipment and support is growing by leaps and bounds every year. MRIs are a revolutionary diagnostic technique that requires the assistance of a human to review and interpret the results. When the technical equipment works but the human aspect does not, it is the patient that is made to suffer, such as in this situation.

The plaintiff's expert testified that the mass was visible, although subtle, on the MRI when done in 2003. If the radiologist who served as the expert could see the mass, why was the hospital-based radiologist who interpreted the MRI in 2003 unable to do so? Is there information regarding who initially read the MRI in 2003? What is the process to request a re-read from a colleague when there are "subtleties" on a film? What was the training of the radiologist to read MRIs? Were there quality control activities in place to provide for re-reads of sample MRIs by the various radiologists credentialed to read MRIs to verify results? What was the rate of mis-reads or missed-reads? What are the medical staff rules regarding the visual acuity of physicians and surgeons? Was impaired vision a factor in missing the mass? Employee job descriptions require 20/20 or 20/30 corrected vision (or they should), but facilities often do not address vision acuity standards for physicians and surgeons.

This 14-year-old came in to the ED with a chief complaint of leg weakness for which she was hospitalized. This scenario does not indicate whether the weakness was an acute onset or had been in evidence for a time and whether she had been being followed by her pediatrician before going to the ED. The defendant hospital blamed the untoward outcome on the failure of the parents to follow-up with a neurologist rather than their pediatrician. This allegation raises the issue of communication and discharge education.

Was the patient referred to a neurologist for follow up or back to the pediatrician? Guillain Barre Syndrome is not a disease/condition usually followed up by a pediatrician without periodic consultation with a neurologist. The discussion by the physician with the patient and her parents regarding the diagnosis and the importance of following up with a neurologist would have been an important aspect of the continuing care of the patient and the discharge preparation and teaching.

Aside from the clinical aspects of this unfortunate case is the insurance, contractual, relationship side. Was the radiologist who interpreted the MRI an employee of the hospital, contracted or independent? What was the relationship with the hospital, and what were the insurance requirements and coverage in place? Was the MRI read by a radiologist off site to whom the MRI was sent electronically?

Even though this incident occurred four years earlier, a root cause analysis is called for to identify the root cause and what interventions and loss control actions can be implemented to prevent a recurrence. Those questions itemized above should be addressed as a part of the hospital's root cause process.


• Sacramento County Superior Court, Case No. 34-2009-00032610.