Julia Pallentino, MSN, JD, ARNP

On returning from a trip to the beach, a 65-year-old Rhode Island woman had worsening foot pain for a day before presenting to a hospital emergency department (ED). The PA who examined her diagnosed a foot sprain, and she was discharged. The PA’s supervising emergency physician, though not consulted, later signed off on the patient’s chart.

In actuality, the woman had a virulent strain of group A streptococcus, which was diagnosed when she returned to the ED two days later. Her condition did not improve, and she died after two days in the hospital.

The plaintiff alleged negligence in the defendant PA’s failure to make a correct diagnosis at the first ED visit. The plaintiff claimed that a blood test should have been performed, as well as a re-check of the decedent’s vital signs. The plaintiff also faulted the PA’s failure to communicate with the defendant emergency physician.

The defendants claimed that the diagnosis of foot sprain was reasonable, and that the PA was qualified to make that diagnosis.

Outcome
A defense verdict was returned.

Comment
When an advanced practice clinician provides care that involves a malpractice claim, it is almost a given that a claim will be made against the supervising physician as well. It is these circumstances that highlight the importance of good communication and support between the two. The facts in this case indicate that the supervising physician signed off on the medical record but did not examine the patient. This is frequently the case in a busy ED, especially when the injury appears to be minor and no complicating factors are evident. The relationship between the two professionals allows the supervising physician to have confidence that the PA is able to make an appropriate diagnostic decision.

There is little in the history presented that would support a finding of malpractice. Pain alone would not likely lead to an alternative diagnosis of virulent strep A infection. Only when the patient returned were symptoms apparently present that led to the alternate diagnosis of a virulent strep A infection. Unfortunately, despite immediate and appropriate treatment, the patient died.

Every defense lawyer knows that defendants who blame each other hand the plaintiff a win. Fortunately, in this case the supervising physician supported the PA’s decision making. Wouldn’t it be better if each professional were considered individually responsible for his or her actions? I believe both patients and physicians would be better served in a system that recognized individual responsibility without reliance on the theory of supervisory liability. —JP

Cases reprinted with permission fromMedical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

On returning from a trip to the beach, a 65-year-old Rhode Island woman had worsening foot pain for a day before presenting to a hospital emergency department (ED). The PA who examined her diagnosed a foot sprain, and she was discharged. The PA’s supervising emergency physician, though not consulted, later signed off on the patient’s chart.

In actuality, the woman had a virulent strain of group A streptococcus, which was diagnosed when she returned to the ED two days later. Her condition did not improve, and she died after two days in the hospital.

The plaintiff alleged negligence in the defendant PA’s failure to make a correct diagnosis at the first ED visit. The plaintiff claimed that a blood test should have been performed, as well as a re-check of the decedent’s vital signs. The plaintiff also faulted the PA’s failure to communicate with the defendant emergency physician.

The defendants claimed that the diagnosis of foot sprain was reasonable, and that the PA was qualified to make that diagnosis.

Outcome
A defense verdict was returned.

Comment
When an advanced practice clinician provides care that involves a malpractice claim, it is almost a given that a claim will be made against the supervising physician as well. It is these circumstances that highlight the importance of good communication and support between the two. The facts in this case indicate that the supervising physician signed off on the medical record but did not examine the patient. This is frequently the case in a busy ED, especially when the injury appears to be minor and no complicating factors are evident. The relationship between the two professionals allows the supervising physician to have confidence that the PA is able to make an appropriate diagnostic decision.

There is little in the history presented that would support a finding of malpractice. Pain alone would not likely lead to an alternative diagnosis of virulent strep A infection. Only when the patient returned were symptoms apparently present that led to the alternate diagnosis of a virulent strep A infection. Unfortunately, despite immediate and appropriate treatment, the patient died.

Every defense lawyer knows that defendants who blame each other hand the plaintiff a win. Fortunately, in this case the supervising physician supported the PA’s decision making. Wouldn’t it be better if each professional were considered individually responsible for his or her actions? I believe both patients and physicians would be better served in a system that recognized individual responsibility without reliance on the theory of supervisory liability. —JP

Cases reprinted with permission fromMedical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

On returning from a trip to the beach, a 65-year-old Rhode Island woman had worsening foot pain for a day before presenting to a hospital emergency department (ED). The PA who examined her diagnosed a foot sprain, and she was discharged. The PA’s supervising emergency physician, though not consulted, later signed off on the patient’s chart.

In actuality, the woman had a virulent strain of group A streptococcus, which was diagnosed when she returned to the ED two days later. Her condition did not improve, and she died after two days in the hospital.

The plaintiff alleged negligence in the defendant PA’s failure to make a correct diagnosis at the first ED visit. The plaintiff claimed that a blood test should have been performed, as well as a re-check of the decedent’s vital signs. The plaintiff also faulted the PA’s failure to communicate with the defendant emergency physician.

The defendants claimed that the diagnosis of foot sprain was reasonable, and that the PA was qualified to make that diagnosis.

Outcome
A defense verdict was returned.

Comment
When an advanced practice clinician provides care that involves a malpractice claim, it is almost a given that a claim will be made against the supervising physician as well. It is these circumstances that highlight the importance of good communication and support between the two. The facts in this case indicate that the supervising physician signed off on the medical record but did not examine the patient. This is frequently the case in a busy ED, especially when the injury appears to be minor and no complicating factors are evident. The relationship between the two professionals allows the supervising physician to have confidence that the PA is able to make an appropriate diagnostic decision.

There is little in the history presented that would support a finding of malpractice. Pain alone would not likely lead to an alternative diagnosis of virulent strep A infection. Only when the patient returned were symptoms apparently present that led to the alternate diagnosis of a virulent strep A infection. Unfortunately, despite immediate and appropriate treatment, the patient died.

Every defense lawyer knows that defendants who blame each other hand the plaintiff a win. Fortunately, in this case the supervising physician supported the PA’s decision making. Wouldn’t it be better if each professional were considered individually responsible for his or her actions? I believe both patients and physicians would be better served in a system that recognized individual responsibility without reliance on the theory of supervisory liability. —JP

Cases reprinted with permission fromMedical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

On returning from a trip to the beach, a 65-year-old Rhode Island woman had worsening foot pain for a day before presenting to a hospital emergency department (ED). The PA who examined her diagnosed a foot sprain, and she was discharged. The PA's supervising emergency physician, though not consulted, later signed off on the patient's chart.

In actuality, the woman had a virulent strain of group A streptococcus, which was diagnosed when she returned to the ED two days later. Her condition did not improve, and she died after two days in the hospital.

The plaintiff alleged negligence in the defendant PA's failure to make a correct diagnosis at the first ED visit. The plaintiff claimed that a blood test should have been performed, as well as a re-check of the decedent's vital signs. The plaintiff also faulted the PA's failure to communicate with the defendant emergency physician.

The defendants claimed that the diagnosis of foot sprain was reasonable, and that the PA was qualified to make that diagnosis.

Outcome
A defense verdict was returned.

Comment
When an advanced practice clinician provides care that involves a malpractice claim, it is almost a given that a claim will be made against the supervising physician as well. It is these circumstances that highlight the importance of good communication and support between the two. The facts in this case indicate that the supervising physician signed off on the medical record but did not examine the patient. This is frequently the case in a busy ED, especially when the injury appears to be minor and no complicating factors are evident. The relationship between the two professionals allows the supervising physician to have confidence that the PA is able to make an appropriate diagnostic decision.

There is little in the history presented that would support a finding of malpractice. Pain alone would not likely lead to an alternative diagnosis of virulent strep A infection. Only when the patient returned were symptoms apparently present that led to the alternate diagnosis of a virulent strep A infection. Unfortunately, despite immediate and appropriate treatment, the patient died.

Every defense lawyer knows that defendants who blame each other hand the plaintiff a win. Fortunately, in this case the supervising physician supported the PA's decision making. Wouldn't it be better if each professional were considered individually responsible for his or her actions? I believe both patients and physicians would be better served in a system that recognized individual responsibility without reliance on the theory of supervisory liability. —JP

Cases reprinted with permission fromMedical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

On returning from a trip to the beach, a 65-year-old Rhode Island woman had worsening foot pain for a day before presenting to a hospital emergency department (ED). The PA who examined her diagnosed a foot sprain, and she was discharged. The PA's supervising emergency physician, though not consulted, later signed off on the patient's chart.

In actuality, the woman had a virulent strain of group A streptococcus, which was diagnosed when she returned to the ED two days later. Her condition did not improve, and she died after two days in the hospital.

The plaintiff alleged negligence in the defendant PA's failure to make a correct diagnosis at the first ED visit. The plaintiff claimed that a blood test should have been performed, as well as a re-check of the decedent's vital signs. The plaintiff also faulted the PA's failure to communicate with the defendant emergency physician.

The defendants claimed that the diagnosis of foot sprain was reasonable, and that the PA was qualified to make that diagnosis.

Outcome
A defense verdict was returned.

Comment
When an advanced practice clinician provides care that involves a malpractice claim, it is almost a given that a claim will be made against the supervising physician as well. It is these circumstances that highlight the importance of good communication and support between the two. The facts in this case indicate that the supervising physician signed off on the medical record but did not examine the patient. This is frequently the case in a busy ED, especially when the injury appears to be minor and no complicating factors are evident. The relationship between the two professionals allows the supervising physician to have confidence that the PA is able to make an appropriate diagnostic decision.

There is little in the history presented that would support a finding of malpractice. Pain alone would not likely lead to an alternative diagnosis of virulent strep A infection. Only when the patient returned were symptoms apparently present that led to the alternate diagnosis of a virulent strep A infection. Unfortunately, despite immediate and appropriate treatment, the patient died.

Every defense lawyer knows that defendants who blame each other hand the plaintiff a win. Fortunately, in this case the supervising physician supported the PA's decision making. Wouldn't it be better if each professional were considered individually responsible for his or her actions? I believe both patients and physicians would be better served in a system that recognized individual responsibility without reliance on the theory of supervisory liability. —JP

Cases reprinted with permission fromMedical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

On returning from a trip to the beach, a 65-year-old Rhode Island woman had worsening foot pain for a day before presenting to a hospital emergency department (ED). The PA who examined her diagnosed a foot sprain, and she was discharged. The PA's supervising emergency physician, though not consulted, later signed off on the patient's chart.

In actuality, the woman had a virulent strain of group A streptococcus, which was diagnosed when she returned to the ED two days later. Her condition did not improve, and she died after two days in the hospital.

The plaintiff alleged negligence in the defendant PA's failure to make a correct diagnosis at the first ED visit. The plaintiff claimed that a blood test should have been performed, as well as a re-check of the decedent's vital signs. The plaintiff also faulted the PA's failure to communicate with the defendant emergency physician.

The defendants claimed that the diagnosis of foot sprain was reasonable, and that the PA was qualified to make that diagnosis.

Outcome
A defense verdict was returned.

Comment
When an advanced practice clinician provides care that involves a malpractice claim, it is almost a given that a claim will be made against the supervising physician as well. It is these circumstances that highlight the importance of good communication and support between the two. The facts in this case indicate that the supervising physician signed off on the medical record but did not examine the patient. This is frequently the case in a busy ED, especially when the injury appears to be minor and no complicating factors are evident. The relationship between the two professionals allows the supervising physician to have confidence that the PA is able to make an appropriate diagnostic decision.

There is little in the history presented that would support a finding of malpractice. Pain alone would not likely lead to an alternative diagnosis of virulent strep A infection. Only when the patient returned were symptoms apparently present that led to the alternate diagnosis of a virulent strep A infection. Unfortunately, despite immediate and appropriate treatment, the patient died.

Every defense lawyer knows that defendants who blame each other hand the plaintiff a win. Fortunately, in this case the supervising physician supported the PA's decision making. Wouldn't it be better if each professional were considered individually responsible for his or her actions? I believe both patients and physicians would be better served in a system that recognized individual responsibility without reliance on the theory of supervisory liability. —JP

Cases reprinted with permission fromMedical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

At an Illinois hospital ED, a 43-year-old man under several physicians' care underwent a CT scan that indicated a possible tear in the aorta. The emergency physician ordered a second CT with contrast, but it was never performed. The emergency physician assumed the test was being done; the patient's cardiologist assumed that the emergency physician was having the test performed; his internist assumed the cardiologist was having the test performed.

Seven hours passed before the patient's aortic tear was diagnosed and he was prepared for surgery. While being transported to the operating room, he experienced cardiac arrest and died.

The decedent had no history of heart problems. Apart from smoking, he had had a healthy lifestyle.

The plaintiff claimed that the defendants failed to diagnose the decedent's condition in a timely fashion.

The defendant hospital admitted negligence but denied that its negligence was causally related to the man's death.

Outcome
According to a published account, the jury awarded $4.5 million, but the recovery was expected to be $3.35 million because of high/low agreements with five of the eight defendants: $2 million to be paid by the hospital, $500,000 to be paid by the emergency physician and his practice group, and $850,000 to be paid by the internist and his practice group.

Comment
This is a tragic case of poor communication. Everyone knew that a CT with contrast had to be performed, and it appears that one was in fact ordered. The emergency physician thought the procedure had been carried out, but it was not done. The other physicians, the cardiologist and the internal medicine specialist, believed that another physician had ordered the test. Seven hours seems like a long time to have passed before anyone realized the procedure was not done, but by then it was clearly too late.

EDs are busy and sometimes confusing places. It is just these circumstances that call for very clear processes to carry out orders, then report findings to the appropriate personnel. The potential chasm between order and report is often a source of medical malpractice, even in medical offices—but the outcome is not usually so dramatic as in this case.

Certainly the argument can be made that the outcome would have been the same. A tear in the aorta may lead to death even in the hands of the best surgeon and even when the patient is otherwise in the best of health. But when a jury sees such a clear case of communication failure as appears here, the outcome is predictable. They will assume that whatever chance this man had was wasted while he waited. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

At an Illinois hospital ED, a 43-year-old man under several physicians' care underwent a CT scan that indicated a possible tear in the aorta. The emergency physician ordered a second CT with contrast, but it was never performed. The emergency physician assumed the test was being done; the patient's cardiologist assumed that the emergency physician was having the test performed; his internist assumed the cardiologist was having the test performed.

Seven hours passed before the patient's aortic tear was diagnosed and he was prepared for surgery. While being transported to the operating room, he experienced cardiac arrest and died.

The decedent had no history of heart problems. Apart from smoking, he had had a healthy lifestyle.

The plaintiff claimed that the defendants failed to diagnose the decedent's condition in a timely fashion.

The defendant hospital admitted negligence but denied that its negligence was causally related to the man's death.

Outcome
According to a published account, the jury awarded $4.5 million, but the recovery was expected to be $3.35 million because of high/low agreements with five of the eight defendants: $2 million to be paid by the hospital, $500,000 to be paid by the emergency physician and his practice group, and $850,000 to be paid by the internist and his practice group.

Comment
This is a tragic case of poor communication. Everyone knew that a CT with contrast had to be performed, and it appears that one was in fact ordered. The emergency physician thought the procedure had been carried out, but it was not done. The other physicians, the cardiologist and the internal medicine specialist, believed that another physician had ordered the test. Seven hours seems like a long time to have passed before anyone realized the procedure was not done, but by then it was clearly too late.

EDs are busy and sometimes confusing places. It is just these circumstances that call for very clear processes to carry out orders, then report findings to the appropriate personnel. The potential chasm between order and report is often a source of medical malpractice, even in medical offices—but the outcome is not usually so dramatic as in this case.

Certainly the argument can be made that the outcome would have been the same. A tear in the aorta may lead to death even in the hands of the best surgeon and even when the patient is otherwise in the best of health. But when a jury sees such a clear case of communication failure as appears here, the outcome is predictable. They will assume that whatever chance this man had was wasted while he waited. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

At an Illinois hospital ED, a 43-year-old man under several physicians' care underwent a CT scan that indicated a possible tear in the aorta. The emergency physician ordered a second CT with contrast, but it was never performed. The emergency physician assumed the test was being done; the patient's cardiologist assumed that the emergency physician was having the test performed; his internist assumed the cardiologist was having the test performed.

Seven hours passed before the patient's aortic tear was diagnosed and he was prepared for surgery. While being transported to the operating room, he experienced cardiac arrest and died.

The decedent had no history of heart problems. Apart from smoking, he had had a healthy lifestyle.

The plaintiff claimed that the defendants failed to diagnose the decedent's condition in a timely fashion.

The defendant hospital admitted negligence but denied that its negligence was causally related to the man's death.

Outcome
According to a published account, the jury awarded $4.5 million, but the recovery was expected to be $3.35 million because of high/low agreements with five of the eight defendants: $2 million to be paid by the hospital, $500,000 to be paid by the emergency physician and his practice group, and $850,000 to be paid by the internist and his practice group.

Comment
This is a tragic case of poor communication. Everyone knew that a CT with contrast had to be performed, and it appears that one was in fact ordered. The emergency physician thought the procedure had been carried out, but it was not done. The other physicians, the cardiologist and the internal medicine specialist, believed that another physician had ordered the test. Seven hours seems like a long time to have passed before anyone realized the procedure was not done, but by then it was clearly too late.

EDs are busy and sometimes confusing places. It is just these circumstances that call for very clear processes to carry out orders, then report findings to the appropriate personnel. The potential chasm between order and report is often a source of medical malpractice, even in medical offices—but the outcome is not usually so dramatic as in this case.

Certainly the argument can be made that the outcome would have been the same. A tear in the aorta may lead to death even in the hands of the best surgeon and even when the patient is otherwise in the best of health. But when a jury sees such a clear case of communication failure as appears here, the outcome is predictable. They will assume that whatever chance this man had was wasted while he waited. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A 45-year-old woman went to the defendant hospital in Alabama for a diagnostic workup. Later that morning, she underwent successful triple cardiac bypass surgery. That evening, while the patient was not on a ventilator and less than 30 minutes after being given an overdose of propofol, she experienced cardiac arrest and was pronounced dead 18 minutes later.

The plaintiff claimed that the nurse who was caring for the decedent made several errors in the administration of propofol. The plaintiff also claimed that the nurse made numerous changes to the record regarding the decedent's vital signs and the ventilator settings. Lastly, the plaintiff claimed that data from the computer memory from the pump used to administer the medication had either been discarded or destroyed.

The decedent's husband had obtained his wife's medical records immediately after her death, and many entries differed from those in the records provided to the plaintiff's attorneys after suit was filed.

Outcome
According to a published account, a $15 million verdict was returned.

Comment
Never, never, ever change a record!

One of the larger plaintiff's verdicts I have recently seen in the literature involves a case of record alteration. As we learned in training, mistakes should be lined out with the correct information added and the date of the alteration indicated. With electronic medical records, the changes are noted and dated, even if the clinician doesn't add in the change date. The computer documents the change without further entry effort.

In this case, it appears that a nurse changed vital signs and ventilator settings. The only reasonable assumption is that it was done to cover up data that would otherwise have been incriminating. Then, to add insult to injury, the propofol pump records were either destroyed or discarded; how convenient. I can only imagine the jurors' thoughts as they heard this.

In addition, there were many other changes to the records. So how was this discovered? The records provided to the plaintiff's husband, probably obtained soon after the incident, differed from those obtained by the plaintiff's attorneys at a later date. I can only guess that no one documented that copies of the record were requested and provided to the husband early on, as would have been good medical record practice.

I have seen just such behavior in my own legal practice. What surprises me here is that the case ever went to trial. Maybe the hoped-for verdict was greater than the available policy limits for settlement, and there was no alternative. In every case that I have seen involving record alteration, a settlement was reached. A smart defense attorney knows that he will have little to offer in defense of this egregious behavior, that a jury will have trouble believing anything the defendants say at trial, and that there is a significant chance for a large and punishing plaintiff's verdict.

We will never know if there was real negligence in this case. When considering record alteration as a way to prevent a malpractice loss, remember that once that alteration comes to light—and it often does—facts mean little. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A 45-year-old woman went to the defendant hospital in Alabama for a diagnostic workup. Later that morning, she underwent successful triple cardiac bypass surgery. That evening, while the patient was not on a ventilator and less than 30 minutes after being given an overdose of propofol, she experienced cardiac arrest and was pronounced dead 18 minutes later.

The plaintiff claimed that the nurse who was caring for the decedent made several errors in the administration of propofol. The plaintiff also claimed that the nurse made numerous changes to the record regarding the decedent's vital signs and the ventilator settings. Lastly, the plaintiff claimed that data from the computer memory from the pump used to administer the medication had either been discarded or destroyed.

The decedent's husband had obtained his wife's medical records immediately after her death, and many entries differed from those in the records provided to the plaintiff's attorneys after suit was filed.

Outcome
According to a published account, a $15 million verdict was returned.

Comment
Never, never, ever change a record!

One of the larger plaintiff's verdicts I have recently seen in the literature involves a case of record alteration. As we learned in training, mistakes should be lined out with the correct information added and the date of the alteration indicated. With electronic medical records, the changes are noted and dated, even if the clinician doesn't add in the change date. The computer documents the change without further entry effort.

In this case, it appears that a nurse changed vital signs and ventilator settings. The only reasonable assumption is that it was done to cover up data that would otherwise have been incriminating. Then, to add insult to injury, the propofol pump records were either destroyed or discarded; how convenient. I can only imagine the jurors' thoughts as they heard this.

In addition, there were many other changes to the records. So how was this discovered? The records provided to the plaintiff's husband, probably obtained soon after the incident, differed from those obtained by the plaintiff's attorneys at a later date. I can only guess that no one documented that copies of the record were requested and provided to the husband early on, as would have been good medical record practice.

I have seen just such behavior in my own legal practice. What surprises me here is that the case ever went to trial. Maybe the hoped-for verdict was greater than the available policy limits for settlement, and there was no alternative. In every case that I have seen involving record alteration, a settlement was reached. A smart defense attorney knows that he will have little to offer in defense of this egregious behavior, that a jury will have trouble believing anything the defendants say at trial, and that there is a significant chance for a large and punishing plaintiff's verdict.

We will never know if there was real negligence in this case. When considering record alteration as a way to prevent a malpractice loss, remember that once that alteration comes to light—and it often does—facts mean little. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A 45-year-old woman went to the defendant hospital in Alabama for a diagnostic workup. Later that morning, she underwent successful triple cardiac bypass surgery. That evening, while the patient was not on a ventilator and less than 30 minutes after being given an overdose of propofol, she experienced cardiac arrest and was pronounced dead 18 minutes later.

The plaintiff claimed that the nurse who was caring for the decedent made several errors in the administration of propofol. The plaintiff also claimed that the nurse made numerous changes to the record regarding the decedent's vital signs and the ventilator settings. Lastly, the plaintiff claimed that data from the computer memory from the pump used to administer the medication had either been discarded or destroyed.

The decedent's husband had obtained his wife's medical records immediately after her death, and many entries differed from those in the records provided to the plaintiff's attorneys after suit was filed.

Outcome
According to a published account, a $15 million verdict was returned.

Comment
Never, never, ever change a record!

One of the larger plaintiff's verdicts I have recently seen in the literature involves a case of record alteration. As we learned in training, mistakes should be lined out with the correct information added and the date of the alteration indicated. With electronic medical records, the changes are noted and dated, even if the clinician doesn't add in the change date. The computer documents the change without further entry effort.

In this case, it appears that a nurse changed vital signs and ventilator settings. The only reasonable assumption is that it was done to cover up data that would otherwise have been incriminating. Then, to add insult to injury, the propofol pump records were either destroyed or discarded; how convenient. I can only imagine the jurors' thoughts as they heard this.

In addition, there were many other changes to the records. So how was this discovered? The records provided to the plaintiff's husband, probably obtained soon after the incident, differed from those obtained by the plaintiff's attorneys at a later date. I can only guess that no one documented that copies of the record were requested and provided to the husband early on, as would have been good medical record practice.

I have seen just such behavior in my own legal practice. What surprises me here is that the case ever went to trial. Maybe the hoped-for verdict was greater than the available policy limits for settlement, and there was no alternative. In every case that I have seen involving record alteration, a settlement was reached. A smart defense attorney knows that he will have little to offer in defense of this egregious behavior, that a jury will have trouble believing anything the defendants say at trial, and that there is a significant chance for a large and punishing plaintiff's verdict.

We will never know if there was real negligence in this case. When considering record alteration as a way to prevent a malpractice loss, remember that once that alteration comes to light—and it often does—facts mean little. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

During a vaginal delivery performed by a nurse-midwife, the infant of a North Carolina woman sustained a moderate brachial plexus injury with shoulder dystocia.

The plaintiff claimed that the nurse-midwife failed to call in her backup physician to help with the delivery. The plaintiff also claimed that the nurse-midwife pulled too hard on the infant’s head during the delivery, leading to the injury. The defendant denied negligence.

Outcome
According to a published account, a $950,000 verdict was returned.

Comment
Cases involving shoulder dystocia in a vaginal delivery are notoriously difficult to defend. Plaintiffs are successful in claiming that infant size, with known potential for shoulder dystocia, should have been anticipated, especially when sonograms are so widely available. Once again, an advanced practice nurse, in this case a nurse-midwife, is faulted for failing to consult a physician. It is no wonder there is such an increase in the number of cesarean deliveries that are being performed. The cost of taking a chance is just too great.

It is difficult to know from the facts presented here whether the nurse-midwife erred. But it is well known among plaintiff lawyers that every parent expects a perfect baby, and when that is not the outcome, someone must be blamed. —JP

Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

During a vaginal delivery performed by a nurse-midwife, the infant of a North Carolina woman sustained a moderate brachial plexus injury with shoulder dystocia.

The plaintiff claimed that the nurse-midwife failed to call in her backup physician to help with the delivery. The plaintiff also claimed that the nurse-midwife pulled too hard on the infant’s head during the delivery, leading to the injury. The defendant denied negligence.

Outcome
According to a published account, a $950,000 verdict was returned.

Comment
Cases involving shoulder dystocia in a vaginal delivery are notoriously difficult to defend. Plaintiffs are successful in claiming that infant size, with known potential for shoulder dystocia, should have been anticipated, especially when sonograms are so widely available. Once again, an advanced practice nurse, in this case a nurse-midwife, is faulted for failing to consult a physician. It is no wonder there is such an increase in the number of cesarean deliveries that are being performed. The cost of taking a chance is just too great.

It is difficult to know from the facts presented here whether the nurse-midwife erred. But it is well known among plaintiff lawyers that every parent expects a perfect baby, and when that is not the outcome, someone must be blamed. —JP

Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

During a vaginal delivery performed by a nurse-midwife, the infant of a North Carolina woman sustained a moderate brachial plexus injury with shoulder dystocia.

The plaintiff claimed that the nurse-midwife failed to call in her backup physician to help with the delivery. The plaintiff also claimed that the nurse-midwife pulled too hard on the infant’s head during the delivery, leading to the injury. The defendant denied negligence.

Outcome
According to a published account, a $950,000 verdict was returned.

Comment
Cases involving shoulder dystocia in a vaginal delivery are notoriously difficult to defend. Plaintiffs are successful in claiming that infant size, with known potential for shoulder dystocia, should have been anticipated, especially when sonograms are so widely available. Once again, an advanced practice nurse, in this case a nurse-midwife, is faulted for failing to consult a physician. It is no wonder there is such an increase in the number of cesarean deliveries that are being performed. The cost of taking a chance is just too great.

It is difficult to know from the facts presented here whether the nurse-midwife erred. But it is well known among plaintiff lawyers that every parent expects a perfect baby, and when that is not the outcome, someone must be blamed. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

The patient, a 50-year-old Pennsylvania woman, underwent a hysterectomy after a uterine fibroid was identified by her treating gynecologists. Because the woman had a history of breast cancer, her doctors also decided to remove her ovaries during the procedure.

According to the patient, her bladder and ureter were transected during the surgery, necessitating a temporary catheter. She was monitored for a year until she changed urologists and underwent a second surgery, during which the ureter was successfully repaired.

The plaintiff claimed that the only way for such an injury to have occurred without negligence was if she had developed scar tissue, and there was no evidence of scar tissue.

The defendants claimed that injury to the ureter is a known complication of the procedure in question. The defendants also claimed that the injury was caused by an electrocautery device that was used during the hysterectomy, and that the actual hole developed two days later and was identified when blood was detected in the plaintiff’s urine.

Outcome
According to a published report, a defense verdict was returned.

Comment
Fortunately, we do not require surgeons to be perfect.  Transecting a ureter is a known, though infrequent, complication of hysterectomy with salpingo-oophorectomy. The injury was discovered and treated, and that is what is necessary. A thorough explanation and apology can go a long way to prevent lawsuits.  Who knows whether open communication and a caring attitude might have prevented this one? —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

The patient, a 50-year-old Pennsylvania woman, underwent a hysterectomy after a uterine fibroid was identified by her treating gynecologists. Because the woman had a history of breast cancer, her doctors also decided to remove her ovaries during the procedure.

According to the patient, her bladder and ureter were transected during the surgery, necessitating a temporary catheter. She was monitored for a year until she changed urologists and underwent a second surgery, during which the ureter was successfully repaired.

The plaintiff claimed that the only way for such an injury to have occurred without negligence was if she had developed scar tissue, and there was no evidence of scar tissue.

The defendants claimed that injury to the ureter is a known complication of the procedure in question. The defendants also claimed that the injury was caused by an electrocautery device that was used during the hysterectomy, and that the actual hole developed two days later and was identified when blood was detected in the plaintiff’s urine.

Outcome
According to a published report, a defense verdict was returned.

Comment
Fortunately, we do not require surgeons to be perfect.  Transecting a ureter is a known, though infrequent, complication of hysterectomy with salpingo-oophorectomy. The injury was discovered and treated, and that is what is necessary. A thorough explanation and apology can go a long way to prevent lawsuits.  Who knows whether open communication and a caring attitude might have prevented this one? —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

The patient, a 50-year-old Pennsylvania woman, underwent a hysterectomy after a uterine fibroid was identified by her treating gynecologists. Because the woman had a history of breast cancer, her doctors also decided to remove her ovaries during the procedure.

According to the patient, her bladder and ureter were transected during the surgery, necessitating a temporary catheter. She was monitored for a year until she changed urologists and underwent a second surgery, during which the ureter was successfully repaired.

The plaintiff claimed that the only way for such an injury to have occurred without negligence was if she had developed scar tissue, and there was no evidence of scar tissue.

The defendants claimed that injury to the ureter is a known complication of the procedure in question. The defendants also claimed that the injury was caused by an electrocautery device that was used during the hysterectomy, and that the actual hole developed two days later and was identified when blood was detected in the plaintiff’s urine.

Outcome
According to a published report, a defense verdict was returned.

Comment
Fortunately, we do not require surgeons to be perfect.  Transecting a ureter is a known, though infrequent, complication of hysterectomy with salpingo-oophorectomy. The injury was discovered and treated, and that is what is necessary. A thorough explanation and apology can go a long way to prevent lawsuits.  Who knows whether open communication and a caring attitude might have prevented this one? —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A 39-year-old man was taken to the defendant hospital following a motor vehicle accident in New York State. He had jaw pain in addition to other complaints, and x-rays were taken. An emergency physician reviewed the results and determined that they were positive for a fracture of the radial head of the right wrist and negative for fractures of the mandible. The patient was treated for the wrist fracture and released.

The next day, hospital radiologists reviewed the man’s x-rays and noted a probable fracture of the right mandibular condyle. A radiologist contacted the emergency department (ED) to report the probable fracture. The emergency physician viewed the patient’s films again but believed that the radiologist was referring to the already diagnosed wrist fracture.

About three weeks later, the patient went to another physician complaining of persistent jaw pain and was sent for further x-rays. A diagnosis was made of a fractured mandible that had developed into a deformity of the mandibular joint. The man required two subsequent surgeries to reconstruct his jaw, but he now has temporomandibular joint dysfunction, a very painful condition.

The plaintiff alleged negligence in the emergency physician’s failure to diagnose the fracture. The hospital interpleaded a nurse practitioner who cared for the plaintiff in the ED and the treating emergency physician. The hospital claimed that the two clinicians were at fault for the delay in diagnosis.

Outcome
According to a published account, a defense verdict was returned.

Comment
Sometimes defendants win, and you can’t help but wonder why. The radiologist’s finding of a mandibular fracture would seem to override an emergency physician’s opinion to the contrary. The failure to correctly communicate or understand which fracture was in contention would not seem to be a very good explanation for this misdiagnosis. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A 39-year-old man was taken to the defendant hospital following a motor vehicle accident in New York State. He had jaw pain in addition to other complaints, and x-rays were taken. An emergency physician reviewed the results and determined that they were positive for a fracture of the radial head of the right wrist and negative for fractures of the mandible. The patient was treated for the wrist fracture and released.

The next day, hospital radiologists reviewed the man’s x-rays and noted a probable fracture of the right mandibular condyle. A radiologist contacted the emergency department (ED) to report the probable fracture. The emergency physician viewed the patient’s films again but believed that the radiologist was referring to the already diagnosed wrist fracture.

About three weeks later, the patient went to another physician complaining of persistent jaw pain and was sent for further x-rays. A diagnosis was made of a fractured mandible that had developed into a deformity of the mandibular joint. The man required two subsequent surgeries to reconstruct his jaw, but he now has temporomandibular joint dysfunction, a very painful condition.

The plaintiff alleged negligence in the emergency physician’s failure to diagnose the fracture. The hospital interpleaded a nurse practitioner who cared for the plaintiff in the ED and the treating emergency physician. The hospital claimed that the two clinicians were at fault for the delay in diagnosis.

Outcome
According to a published account, a defense verdict was returned.

Comment
Sometimes defendants win, and you can’t help but wonder why. The radiologist’s finding of a mandibular fracture would seem to override an emergency physician’s opinion to the contrary. The failure to correctly communicate or understand which fracture was in contention would not seem to be a very good explanation for this misdiagnosis. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A 39-year-old man was taken to the defendant hospital following a motor vehicle accident in New York State. He had jaw pain in addition to other complaints, and x-rays were taken. An emergency physician reviewed the results and determined that they were positive for a fracture of the radial head of the right wrist and negative for fractures of the mandible. The patient was treated for the wrist fracture and released.

The next day, hospital radiologists reviewed the man’s x-rays and noted a probable fracture of the right mandibular condyle. A radiologist contacted the emergency department (ED) to report the probable fracture. The emergency physician viewed the patient’s films again but believed that the radiologist was referring to the already diagnosed wrist fracture.

About three weeks later, the patient went to another physician complaining of persistent jaw pain and was sent for further x-rays. A diagnosis was made of a fractured mandible that had developed into a deformity of the mandibular joint. The man required two subsequent surgeries to reconstruct his jaw, but he now has temporomandibular joint dysfunction, a very painful condition.

The plaintiff alleged negligence in the emergency physician’s failure to diagnose the fracture. The hospital interpleaded a nurse practitioner who cared for the plaintiff in the ED and the treating emergency physician. The hospital claimed that the two clinicians were at fault for the delay in diagnosis.

Outcome
According to a published account, a defense verdict was returned.

Comment
Sometimes defendants win, and you can’t help but wonder why. The radiologist’s finding of a mandibular fracture would seem to override an emergency physician’s opinion to the contrary. The failure to correctly communicate or understand which fracture was in contention would not seem to be a very good explanation for this misdiagnosis. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A Massachusetts woman, age 43, presented to her physician’s office complaining of a throbbing headache that had worsened progressively over the previous 48 hours. She was seen by a covering physician to whom she reported symptoms of nausea, vomiting, and photophobia. She had a history of headaches, which she attributed to a previous ear surgery.

The covering physician treated the patient with pain and anti-nausea medications and told her to follow up with her regular primary care provider. The woman went home and fell asleep on her couch. She later died in her sleep. Autopsy findings indicated that the cause of death was bacterial meningitis.

The plaintiff claimed that the question of whether the defendant physician should have considered bacterial meningitis turned on the presence of nuchal rigidity (stiff neck). The defendant conceded that if he had noticed nuchal rigidity, he would have entertained bacterial meningitis in the differential diagnosis. He testified that the decedent was negative for nuchal rigidity but that he had not recorded that finding. The plaintiff presented witnesses who observed that the woman was unable to move her neck during the time of her illness.

Outcome
A $1.45 million settlement was reached.

Comment
This is a classic case of documentation failure. Clearly, not every detail of every exam can be documented in a busy practice, but when a diagnostic decision is made based upon a defining symptom, as it was in this case, then the presence or absence of the defining symptom must be documented. Here, nuchal rigidity is the factor that distinguishes a routine headache from a headache that may be related to bacterial meningitis. Testimony without a record to back it up when it relates to this crucial fact may well have made the difference between a defense and plaintiff’s verdict. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A Massachusetts woman, age 43, presented to her physician’s office complaining of a throbbing headache that had worsened progressively over the previous 48 hours. She was seen by a covering physician to whom she reported symptoms of nausea, vomiting, and photophobia. She had a history of headaches, which she attributed to a previous ear surgery.

The covering physician treated the patient with pain and anti-nausea medications and told her to follow up with her regular primary care provider. The woman went home and fell asleep on her couch. She later died in her sleep. Autopsy findings indicated that the cause of death was bacterial meningitis.

The plaintiff claimed that the question of whether the defendant physician should have considered bacterial meningitis turned on the presence of nuchal rigidity (stiff neck). The defendant conceded that if he had noticed nuchal rigidity, he would have entertained bacterial meningitis in the differential diagnosis. He testified that the decedent was negative for nuchal rigidity but that he had not recorded that finding. The plaintiff presented witnesses who observed that the woman was unable to move her neck during the time of her illness.

Outcome
A $1.45 million settlement was reached.

Comment
This is a classic case of documentation failure. Clearly, not every detail of every exam can be documented in a busy practice, but when a diagnostic decision is made based upon a defining symptom, as it was in this case, then the presence or absence of the defining symptom must be documented. Here, nuchal rigidity is the factor that distinguishes a routine headache from a headache that may be related to bacterial meningitis. Testimony without a record to back it up when it relates to this crucial fact may well have made the difference between a defense and plaintiff’s verdict. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A Massachusetts woman, age 43, presented to her physician’s office complaining of a throbbing headache that had worsened progressively over the previous 48 hours. She was seen by a covering physician to whom she reported symptoms of nausea, vomiting, and photophobia. She had a history of headaches, which she attributed to a previous ear surgery.

The covering physician treated the patient with pain and anti-nausea medications and told her to follow up with her regular primary care provider. The woman went home and fell asleep on her couch. She later died in her sleep. Autopsy findings indicated that the cause of death was bacterial meningitis.

The plaintiff claimed that the question of whether the defendant physician should have considered bacterial meningitis turned on the presence of nuchal rigidity (stiff neck). The defendant conceded that if he had noticed nuchal rigidity, he would have entertained bacterial meningitis in the differential diagnosis. He testified that the decedent was negative for nuchal rigidity but that he had not recorded that finding. The plaintiff presented witnesses who observed that the woman was unable to move her neck during the time of her illness.

Outcome
A $1.45 million settlement was reached.

Comment
This is a classic case of documentation failure. Clearly, not every detail of every exam can be documented in a busy practice, but when a diagnostic decision is made based upon a defining symptom, as it was in this case, then the presence or absence of the defining symptom must be documented. Here, nuchal rigidity is the factor that distinguishes a routine headache from a headache that may be related to bacterial meningitis. Testimony without a record to back it up when it relates to this crucial fact may well have made the difference between a defense and plaintiff’s verdict. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A 64-year-old Alabama man, while dismounting from a dolly at work, lost his footing and fell back-first, landing on his shoulders but also striking the back of his neck and the back of his head. He later reported that he felt his neck pop before he lost consciousness. A coworker found the injured man, and he was quickly evaluated by a nurse in the employer’s medical office. No bumps or bruises were found, and the patient was given acetaminophen and instructed to rest on a heating pad for half an hour or so. He rested for some additional time before returning to work.

When the man arrived home that evening, he went to sleep. When he awoke, he was experiencing significant neck pain and he was taken to an emergency department (ED). He was treated in the ED by Dr. E. X-rays were taken, but they revealed nothing. The plaintiff was discharged after administration of pain medication, a muscle relaxer, and an anti-inflammatory agent.

The following day, the patient had trouble walking and using the bathroom. He was taken to Dr. J., who ordered an MRI that was performed three days after the patient’s accident. The day after the MRI, the patient was unable to get out of bed or move his legs, and his neck pain had worsened. He was taken by ambulance to a hospital, where additional x-rays were taken. Two fractures were found in his neck, which were exerting pressure against the spinal cord. The man was also diagnosed with a bruise on the spine on the back of the neck. He underwent surgery, but his disability persisted.

The plaintiff alleged negligence in the medical providers’ failure to make an earlier diagnosis of the spinal cord injury. The plaintiff claimed that a timely diagnosis and treatment with steroids would have changed his outcome.

The defendants claimed that no negligence was involved and that the plaintiff’s outcome would have been the same, even with earlier treatment. The only defendant at trial was Dr. E.

Outcome
The patient died in 2008, and his estate was substituted as plaintiff. According to a published report, a defense verdict was returned.

Comment
In this defense verdict, it appears that everyone did the right thing, but that technology failed to properly identify the real injury. On the day of the unwitnessed accident, the patient’s physical exam revealed no findings suggestive of spinal injury. Signs and symptoms that developed on the day after the accident were suggestive of spinal injury, but x-rays ordered by the defendant emergency physician failed to reveal any abnormality; the patient’s symptoms could easily have been explained by muscle pain and soreness attributable to his accident. Certainly, in retrospect, everyone wishes that an MRI had been performed on Day 1. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A 64-year-old Alabama man, while dismounting from a dolly at work, lost his footing and fell back-first, landing on his shoulders but also striking the back of his neck and the back of his head. He later reported that he felt his neck pop before he lost consciousness. A coworker found the injured man, and he was quickly evaluated by a nurse in the employer’s medical office. No bumps or bruises were found, and the patient was given acetaminophen and instructed to rest on a heating pad for half an hour or so. He rested for some additional time before returning to work.

When the man arrived home that evening, he went to sleep. When he awoke, he was experiencing significant neck pain and he was taken to an emergency department (ED). He was treated in the ED by Dr. E. X-rays were taken, but they revealed nothing. The plaintiff was discharged after administration of pain medication, a muscle relaxer, and an anti-inflammatory agent.

The following day, the patient had trouble walking and using the bathroom. He was taken to Dr. J., who ordered an MRI that was performed three days after the patient’s accident. The day after the MRI, the patient was unable to get out of bed or move his legs, and his neck pain had worsened. He was taken by ambulance to a hospital, where additional x-rays were taken. Two fractures were found in his neck, which were exerting pressure against the spinal cord. The man was also diagnosed with a bruise on the spine on the back of the neck. He underwent surgery, but his disability persisted.

The plaintiff alleged negligence in the medical providers’ failure to make an earlier diagnosis of the spinal cord injury. The plaintiff claimed that a timely diagnosis and treatment with steroids would have changed his outcome.

The defendants claimed that no negligence was involved and that the plaintiff’s outcome would have been the same, even with earlier treatment. The only defendant at trial was Dr. E.

Outcome
The patient died in 2008, and his estate was substituted as plaintiff. According to a published report, a defense verdict was returned.

Comment
In this defense verdict, it appears that everyone did the right thing, but that technology failed to properly identify the real injury. On the day of the unwitnessed accident, the patient’s physical exam revealed no findings suggestive of spinal injury. Signs and symptoms that developed on the day after the accident were suggestive of spinal injury, but x-rays ordered by the defendant emergency physician failed to reveal any abnormality; the patient’s symptoms could easily have been explained by muscle pain and soreness attributable to his accident. Certainly, in retrospect, everyone wishes that an MRI had been performed on Day 1. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A 64-year-old Alabama man, while dismounting from a dolly at work, lost his footing and fell back-first, landing on his shoulders but also striking the back of his neck and the back of his head. He later reported that he felt his neck pop before he lost consciousness. A coworker found the injured man, and he was quickly evaluated by a nurse in the employer’s medical office. No bumps or bruises were found, and the patient was given acetaminophen and instructed to rest on a heating pad for half an hour or so. He rested for some additional time before returning to work.

When the man arrived home that evening, he went to sleep. When he awoke, he was experiencing significant neck pain and he was taken to an emergency department (ED). He was treated in the ED by Dr. E. X-rays were taken, but they revealed nothing. The plaintiff was discharged after administration of pain medication, a muscle relaxer, and an anti-inflammatory agent.

The following day, the patient had trouble walking and using the bathroom. He was taken to Dr. J., who ordered an MRI that was performed three days after the patient’s accident. The day after the MRI, the patient was unable to get out of bed or move his legs, and his neck pain had worsened. He was taken by ambulance to a hospital, where additional x-rays were taken. Two fractures were found in his neck, which were exerting pressure against the spinal cord. The man was also diagnosed with a bruise on the spine on the back of the neck. He underwent surgery, but his disability persisted.

The plaintiff alleged negligence in the medical providers’ failure to make an earlier diagnosis of the spinal cord injury. The plaintiff claimed that a timely diagnosis and treatment with steroids would have changed his outcome.

The defendants claimed that no negligence was involved and that the plaintiff’s outcome would have been the same, even with earlier treatment. The only defendant at trial was Dr. E.

Outcome
The patient died in 2008, and his estate was substituted as plaintiff. According to a published report, a defense verdict was returned.

Comment
In this defense verdict, it appears that everyone did the right thing, but that technology failed to properly identify the real injury. On the day of the unwitnessed accident, the patient’s physical exam revealed no findings suggestive of spinal injury. Signs and symptoms that developed on the day after the accident were suggestive of spinal injury, but x-rays ordered by the defendant emergency physician failed to reveal any abnormality; the patient’s symptoms could easily have been explained by muscle pain and soreness attributable to his accident. Certainly, in retrospect, everyone wishes that an MRI had been performed on Day 1. —JP