The following transcript was adapted from Resource, RMF's monthly audiotape; July 2002

A 49-year-old woman with a history of MS was seen in the ED after a seizure. After being moved to a radiology suite outside the ED she suffered respiratory arrest and died the following day.

Clinical Sequence

Janet Kimble, 49 years old, was brought to the ED by her parents after a seizure with a prolonged postictal state and a distended abdomen. Kimble had a history of MS with chronic bowel problems. She was bedridden and non-verbal. The ED physician called a surgical resident who ordered a KUB, a rigid sigmoidoscopy, and a gastrografin enema. No NG tube was inserted.

The radiology equipment adjacent to the ED was not working. So the patient was taken by a transporter to another radiology suite in a remote location several floors from the ED. When the radiology resident brought the patient back to the ED, she was pale and lethargic with vomitus on her face. Shortly after her return, she had a respiratory arrest and died the next day.
Her parents were angry at what appeared to be a prolonged stay in the radiology suite unattended. They sued the ED physician, the surgical resident, and several nurses, claiming their alleged failure to properly monitor their daughter's condition resulted in her death.

Claim Sequence

The patient's estate alleged failure to monitor her led to her death.

Disposition

The suit was settled in the mid-range.

Discussion Points

To discuss the risk management implications of this case, Resource speaks with Peggy Berry Martin. Ms. Martin is director of education for Risk Management Foundation.

Peggy, many times a case is settled after some negative expert reviews. What did the reviewers in this case find?

1. Experts were divided on whether the an NG tube should have been inserted.
2. Lack of documentation meant that there was a substantial period of time in which a severely compromised patient could have been alone and forgotten, subsequently aspiring vomit which may have lead to her death.

The care obviously didn't meet the expectations of the family.

Parents had cared for this woman for many years and while they knew she was most likely terminal, were angry that she may have been left alone for an undetermined amount of time.

Even if the outcome wouldn't necessarily change, what improvements could be made in how the patient was handled? Medicine was probably within the standard of care but systems issues were problematic:

Procedures to be followed by ED personnel when an alternative radiology suite had to be used, i.e., additional monitoring for a very compromised patient, nurse transport instead of a transporter, communication with radiology personnel about the patient's condition before she was sent.