A nine-year-old boy with flu-like symptoms died at home from diabetic ketoacidosis, after his father received phone advice overnight from a nurse practitioner unaware of the child’s (undiagnosed) diabetes mellitus.

Key Lessons

  • Many illnesses can mimic others, and noting any subtle differences can be very difficult without actually seeing the patient or obtaining diagnostic tests.
  • Clinicians triaging patients over the phone should err on the side of either bringing the patient into the office to be seen or, if the office is closed, sending them to the ED for evaluation.
  • Clinical staff should carefully and accurately document telephone encounters with patients.

Clinical Sequence

An otherwise healthy nine-year-old boy developed flu-like symptoms (nausea/vomiting, decreased oral intake, lethargy, and weakness). After three days, the boy’s father called the pediatrician’s office at 8:00 on a Saturday night. The on-call nurse practitioner returned the call (which was recorded). The father relayed the symptoms and said that Gatorade was making the boy nauseous, but he was still drinking some ginger ale. The father expressed concern about how tired his son was—he’d slept for 24 hours straight (from 8:00 p.m. the previous night). The boy woke up only to be carried downstairs to watch some TV for a little while. He felt a little better than the day before, but he also had some rectal bleeding and some bleeding from his mouth.

The NP acknowledged the boy’s symptoms and said that most of it sounded like a viral illness, but that the rectal bleeding could be something different. She asked the father several questions in order to get a better understanding of the boy’s condition, including:

  • Was he alert? (father’s response: yes but very tired)
  • Had he passed any urine? (response: yes)
  • Did he have a fever or rash? (response: no)

The NP then asked the father whether he thought the child was “OK” tonight or felt he should be seen right away. The father replied that he didn’t think he needed to be seen right now. The NP agreed and made plans for him to be seen in the office the next morning (Sunday) after 8:00. She told him to call back if anything developed during the night. The father asked, “I don’t need to worry about him not taking any food? He is taking some ginger ale.” The NP responded by telling him to push the ginger ale and make sure he’s urinating periodically. The NP documented the call in the medical record, including that the father was offered an ED visit (although that was not specifically said, per the audio recording).

At about 4:00 a.m., the father checked in on his son and noted that he was sleeping but that his breathing rate had increased. At about 8:30 a.m., when the father again checked on his son, he was not breathing. He called 911 and started CPR. The ambulance and EMTs arrived within minutes and found the child apneic, pulseless, with fixed and dilated pupils, and his corneas cloudy. At 9:30 a.m., the child was pronounced dead.

An autopsy found the cause of death to be diabetic ketoacidosis (the child had undiagnosed diabetes mellitus). His blood sugar was 1,165 (nl 50–80); potassium was 7.1 (nl 3.5–5.3); and his HgA1C was 15.3% (nl 4–5.9%).


The parents sued the nurse practitioner, alleging wrongful death of their son due to negligent delay in diagnosis and treatment of diabetic ketoacidosis.


The case was settled in the high range against the nurse practitioner.


  1. The NP did not adequately assess the severity of the patient’s symptoms (failing to identify that the patient’s bleeding from two sites, extreme weakness and lethargy—the patient slept for 24 hours—were symptoms of a potentially life-threatening emergency).
    Many illnesses can mimic others: diabetic ketoacidosis (a life-threatening condition) can mimic common flu symptoms (nausea/vomiting, anorexia, lethargy and weakness). Noting the subtle differences, without actually seeing the patient or obtaining diagnostic tests, can be very difficult. Clinicians providing telephone triage to patients should listen intently to the patient’s list of symptoms, trying not to rush or interrupt them, following up with open-ended questions. If still unable to identify the potential cause, err on the side of either bringing the patient into the office to be seen or, if the office is closed, sending him or her to the ED for evaluation.
  2. Inadequate communication between clinician and patient/family: the NP thought she had offered the father the option of bringing his son to the ED to be evaluated but had actually only asked the father if he thought the patient needed to be seen. During this malpractice case, it became clear that both the NP and the father had very different interpretations of how their conversation wentillustrated by the actual transcript of the conversation.
    Many patients (or their parents/guardians) are reluctant to call a doctor’s office, especially during off-hours. They often feel that their complaint may be seen as trivial or that they are inconveniencing the physician or clinical staff. Patients should be reassured that this isn’t true, and encouraged to call when they have questions or concerns regarding their health.

    At the end of a call, the clinician should make sure the patient/family has a good understanding of the nature of their symptoms and what actions, if any, they should take. They should be given specific instructions when to call back or go to the ED. Phone ahead and let the ED staff know what your presumptive diagnosis is or give a description of the patient’s symptoms.
  3. The medical record did not accurately depict the conversation the NP had with the father as it was audio recorded.
    Clinical staff need to carefully document their telephone encounters, including date, time, specific complaints, assessment, advice, final disposition of the call, and any referrals to other providers or facilities. Instructions regarding medications, interventions, and when to return to the office or go to the ED should also be documented. Remember that subsequent providers will need documentation of after-hour and weekend patient calls as well.

For More Information

FAQs: "What are the patient safety issues surrounding medical advice via telephone?"

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