Legal Review and Commentary: Adult meningitis goes undetected, resulting in death: $2.5 million Ohio settlement
By Jan J. Gorrie, Esq., and Mark K. Delegal, Esq. Pennington, Moore, Wilkinson, Bell & Dunbar, PA Tallahassee, FLNews: After three trips to a hospital emergency department (ED), a 32-year-old woman’s meningitis went undetected for days. The lack of timely treatment with antibiotics resulted in her death. The case was confidentially settled during the trial against the hospital for $2.5 million.
Background: The otherwise healthy patient was the activities director for the defendant hospital’s skilled nursing facility. She initially presented to her employer’s ED Sept. 29, complaining of an earache in her left ear and a moderate headache. After being triaged, she was directed to the hospital’s ED, which also is a primary care clinic. She was then diagnosed by a family practitioner as having an infection in her left ear. The hospital-employed physician prescribed a customary dosage of the antibiotic Zithromax. She was discharged home and advised to seek further medical attention if her condition worsened.
The patient went home and took the antibiotic as directed. The next day, her condition significantly deteriorated, including a fever, unrelenting pain in her left ear, headache, and chills. She returned to the hospital’s ED, was triaged again, then directed to the primary care clinic. While being examined, the patient cried profusely because her pain was so intense. However, despite her new symptoms and significant pain-induced distress, no neck exam was performed, no diagnostic studies were conducted, and her antibiotics were not changed. This time, the employee physician diagnosed her as having a perforated right eardrum in addition to the left ear infection. The patient was simply discharged home with some pain medication in addition to the Zithromax and, again, instructed to return if her pain persisted or condition worsened.
On Oct. 2, just three days after her initial visit, the woman’s mother took her back to the hospital because her advanced symptoms precluded her from driving. The patient now complained of a throbbing headache, drowsiness, a very stiff neck, and photophobia, which is abnormal sensitivity to light. On this visit, she was not directed to the clinic but treated in the ED. The ED attending physician initially gave the patient Demerol and Compazine for her pain and mental state. After making a working diagnosis of meningitis, there was at least a two-hour delay in administering vancomycin. However, in addition to the delay in giving her the appropriate drug to treat the serious infection, she only was given 1 g, even though the recommended dose is double that amount. Further, despite the intensity of her headache, the physician did not order a CT scan, but instead performed a lumbar puncture. As a result of the procedure, the patient’s brain herniated, and she expired.
The decedent’s mother brought suit against the hospital. With regard to the first and second ED visits, the plaintiff contended that while the underlying cause of the ear problems went undetected, the medications prescribed for the left ear infection and right ear perforation were inappropriate. Specifically, the mother claimed that instead of Zithromax, her daughter should have been given erythromycin.
The first and second ED visits aside, the plaintiff alleged that on the final visit to the hospital, the patient’s deteriorating mental status should have been serially monitored, but instead the patient was inappropriately given a dose of Demerol and Compazine. The plaintiff claimed that these drugs masked the actual underlying cause of her daughter’s condition because when the patient’s mental status further deteriorated over time, it was erroneously attributed to the administration of these sedation-effect drugs and not to meningitis. Further, the plaintiff alleged that her daughter’s drowsiness should have alerted the physician to the fact that she might have early signs of increased intracranial pressure, for which there is a significant risk of brain herniation with a lumbar puncture. The plaintiff contended that had the ED physician ordered a CT scan first, it would have been apparent that the decedent had increased intracranial pressure as a partial foundation for her prominent headache pain. However, the ED physician performed a lumbar puncture in the face of this increased intracranial pressure, her brain herniated, and the patient expired.
Finally, the plaintiff argued that the paramount concern for any patient suspected of having bacterial meningitis is the timely administration of an appropriate dose of antibiotics. The decedent was not given her first dose of antibiotics until nearly two hours after initial evaluation, and she was given a suboptimal dose — one that was insufficient to stem the development of further serious and, in this case, life-threatening infection. At trial, even the hospital’s expert stated that as soon as the working diagnosis of meningitis was made, combative antibiotics should have been administered within 30 minutes of such diagnosis at appropriate levels to treat the aggressive infection.
The plaintiff averred that the patient had relied on her employer’s ED personnel to properly diagnose and treat her; however, they fell below the standard of care in not recognizing the progression of meningitis. The plaintiff claimed that the array and severity of symptoms on the third ED visit should have been timely interpreted as meningitis and treated accordingly. After the plaintiff presented her case at trial, the hospital confidentially settled for $2.5 million.
What this means to you: "From the facts provided, the patient’s initial visit to the emergency room seems perfectly appropriate, as does the triage to the primary care clinic. However, things go downhill from there. The second visit made 24 hours after the first was the key visit to correctly diagnose and treat the patient," opines Ellen Barton, JD, CPCU, a Phoenix, MD-based risk management consultant.
"The second visit is problematic for several reasons and raises several questions. Was the triage to primary care appropriate? When an otherwise healthy 32-year-old returns to the emergency room within 24 hours and her condition is significantly worse, shouldn’t a red flag go up? Further, to worsen after 24 hours on antibiotics means that the choice of antibiotics has to be questioned. Finally, when a patient has fever and chills, perhaps an infectious disease specialist should have been called in to explore potential signs of septicemia," she states.
"As for the third and final visit to the emergency room, it is unlikely that the patient could have been saved (without neurological impairment) even if the appropriate dosage of antibiotics had been given immediately upon her arrival at the emergency room. Intravenous antibiotics were needed stat! While the patient was actually seen in the emergency room on this visit as opposed to being directed to the primary care clinic, the medical judgment exercised was problematic and only made a bad situation worse," says Barton.
"While the basis of negligence in this case clearly appears to be poor medical judgment (not once, but twice — the second primary care physician and the emergency room attending physician), there are a couple of things the hospital could have done to create a setting where the likelihood of poor medical judgment being exercised may be decreased:
"1. The hospital’s policies and procedures should provide for specific protocols when a patient returns to the emergency room once or multiple times: a) within 24 hours; b) within 48 hours; c) within 72 hours. The red flags should go up, and such patients should be regarded as high risk.
"2. The hospital’s triage system should be thoroughly reviewed to be certain that the criteria used to triage are appropriate. In addition, the personnel exercising judgment regarding triage decisions need to be appropriately qualified to make such judgments. Lastly, there should be very clear criteria regarding the referral to primary care.
"3. While this case is based on physician negligence (albeit hospital employees), a hospital may wish to contract for emergency room medical services and to require that the emergency medicine physicians not only provide their own insurance but also indemnify the hospital for any amounts the hospital might become liable to pay because of the physicians’ negligence. (The primary care physician was clearly a hospital employee; however, it is unclear from the facts presented if the emergency room attending physician was also an employee). Although with the focus on the third visit, it appears that he was either a hospital employee or a contracted employee for whom the hospital had undertaken to provide liability coverage," concludes Barton.
Reference
- John Doe, Administratrix of the Estate of Jane Doe v. ABC Hospital, Cuyahoga County (OH), Court of Common Pleas. Laurel Matthews of Cleveland for the plaintiff.
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