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Would a cholesterol medication have made a difference? … More
Would a cholesterol medication have made a difference?
A WOMAN WITH A HISTORY OF HYPERTENSION and hyperlipidemia sought treatment from her family physician (FP) for a protracted, nonproductive cough. The FP diagnosed sinusitis and reactive airway disease and prescribed steroids and antibiotics. The patient returned to the FP 5 more times over the next 9 weeks. The patient’s symptoms waxed and waned, but her cough continued. She reported chest tightness and shortness of breath on exertion. A chest x-ray revealed moderate heart enlargement. An echocardiogram was scheduled.
During the patient’s last visit, her FP noted that she had shortness of breath on exertion, but no chest pain. Three days later she suffered a massive myocardial infarction (MI). Cardiac catheterization found 80% occlusion of the left anterior descending artery. She underwent angioplasty and stent placement; after this procedure her ejection fraction was 25% to 30%. One month later, the patient received a pacemaker/defibrillator. The patient’s cardiac symptoms returned 7 months later, and she underwent another angioplasty. She improved and her last echocardiogram showed near-normal heart function.
PLAINTIFF’S CLAIM Although the patient had persistently elevated cholesterol levels, the FP failed to order repeat cholesterol studies and arrange for drug therapy. If the patient’s hyperlipidemia had been medically managed, her coronary artery disease would not have progressed to unstable angina and MI. The FP also failed to obtain routine electrocardiograms or an urgent cardiac consult after a chest x-ray showed an enlarged heart. The FP also failed to send the patient to an emergency department when she complained of shortness of breath on exertion.
THE DEFENSE An urgent cardiac work-up was not indicated and the patient’s cholesterol levels were only mildly elevated and did not require medical management. Her MI was unavoidable since most infarctions are due to plaque rupture in coronary vessels that aren’t occluded enough to require treatment.
VERDICT $1.6 million Michigan verdict.
COMMENT I think the key issue in this difficult diagnostic case is not the lack of prescribing cholesterol medication, but the repeated office visits with no definite diagnosis. If the physician had escalated the evaluation more quickly, the MI might have been avoided.
Narcotic misstep has tragic consequences
A 47-YEAR-OLD MAN SOUGHT TREATMENT FOR DRUG ADDICTION. His physician prescribed methadone, despite not being licensed to do so. After 4 days of taking methadone, the patient went to the hospital because he felt dizzy and was having difficulty breathing. Two days after being examined and discharged, he died from methadone toxicity.
PLAINTIFF’S CLAIM The toxicity was caused by simultaneous use of methadone and alprazolam, which the patient also had been prescribed. The physician failed to recognize the potential toxicity and should have performed testing that could have revealed the simultaneous use of other drugs. In addition, the physician was not licensed to prescribe methadone.
THE DEFENSE The physician had recommended a licensed, qualified facility that could have treated the plaintiff, but the plaintiff preferred treatment in a setting that allowed him to remain anonymous.
VERDICT $1.15 million New York settlement.
COMMENT Don’t break the law, even if your patient asks you to. Know your state laws regarding narcotic prescribing. These are getting more stringent due to the rapid rise in prescription narcotic overdose deaths in the United States.
Would a cholesterol medication have made a difference?
A WOMAN WITH A HISTORY OF HYPERTENSION and hyperlipidemia sought treatment from her family physician (FP) for a protracted, nonproductive cough. The FP diagnosed sinusitis and reactive airway disease and prescribed steroids and antibiotics. The patient returned to the FP 5 more times over the next 9 weeks. The patient’s symptoms waxed and waned, but her cough continued. She reported chest tightness and shortness of breath on exertion. A chest x-ray revealed moderate heart enlargement. An echocardiogram was scheduled.
During the patient’s last visit, her FP noted that she had shortness of breath on exertion, but no chest pain. Three days later she suffered a massive myocardial infarction (MI). Cardiac catheterization found 80% occlusion of the left anterior descending artery. She underwent angioplasty and stent placement; after this procedure her ejection fraction was 25% to 30%. One month later, the patient received a pacemaker/defibrillator. The patient’s cardiac symptoms returned 7 months later, and she underwent another angioplasty. She improved and her last echocardiogram showed near-normal heart function.
PLAINTIFF’S CLAIM Although the patient had persistently elevated cholesterol levels, the FP failed to order repeat cholesterol studies and arrange for drug therapy. If the patient’s hyperlipidemia had been medically managed, her coronary artery disease would not have progressed to unstable angina and MI. The FP also failed to obtain routine electrocardiograms or an urgent cardiac consult after a chest x-ray showed an enlarged heart. The FP also failed to send the patient to an emergency department when she complained of shortness of breath on exertion.
THE DEFENSE An urgent cardiac work-up was not indicated and the patient’s cholesterol levels were only mildly elevated and did not require medical management. Her MI was unavoidable since most infarctions are due to plaque rupture in coronary vessels that aren’t occluded enough to require treatment.
VERDICT $1.6 million Michigan verdict.
COMMENT I think the key issue in this difficult diagnostic case is not the lack of prescribing cholesterol medication, but the repeated office visits with no definite diagnosis. If the physician had escalated the evaluation more quickly, the MI might have been avoided.
Narcotic misstep has tragic consequences
A 47-YEAR-OLD MAN SOUGHT TREATMENT FOR DRUG ADDICTION. His physician prescribed methadone, despite not being licensed to do so. After 4 days of taking methadone, the patient went to the hospital because he felt dizzy and was having difficulty breathing. Two days after being examined and discharged, he died from methadone toxicity.
PLAINTIFF’S CLAIM The toxicity was caused by simultaneous use of methadone and alprazolam, which the patient also had been prescribed. The physician failed to recognize the potential toxicity and should have performed testing that could have revealed the simultaneous use of other drugs. In addition, the physician was not licensed to prescribe methadone.
THE DEFENSE The physician had recommended a licensed, qualified facility that could have treated the plaintiff, but the plaintiff preferred treatment in a setting that allowed him to remain anonymous.
VERDICT $1.15 million New York settlement.
COMMENT Don’t break the law, even if your patient asks you to. Know your state laws regarding narcotic prescribing. These are getting more stringent due to the rapid rise in prescription narcotic overdose deaths in the United States.
Would a cholesterol medication have made a difference?
A WOMAN WITH A HISTORY OF HYPERTENSION and hyperlipidemia sought treatment from her family physician (FP) for a protracted, nonproductive cough. The FP diagnosed sinusitis and reactive airway disease and prescribed steroids and antibiotics. The patient returned to the FP 5 more times over the next 9 weeks. The patient’s symptoms waxed and waned, but her cough continued. She reported chest tightness and shortness of breath on exertion. A chest x-ray revealed moderate heart enlargement. An echocardiogram was scheduled.
During the patient’s last visit, her FP noted that she had shortness of breath on exertion, but no chest pain. Three days later she suffered a massive myocardial infarction (MI). Cardiac catheterization found 80% occlusion of the left anterior descending artery. She underwent angioplasty and stent placement; after this procedure her ejection fraction was 25% to 30%. One month later, the patient received a pacemaker/defibrillator. The patient’s cardiac symptoms returned 7 months later, and she underwent another angioplasty. She improved and her last echocardiogram showed near-normal heart function.
PLAINTIFF’S CLAIM Although the patient had persistently elevated cholesterol levels, the FP failed to order repeat cholesterol studies and arrange for drug therapy. If the patient’s hyperlipidemia had been medically managed, her coronary artery disease would not have progressed to unstable angina and MI. The FP also failed to obtain routine electrocardiograms or an urgent cardiac consult after a chest x-ray showed an enlarged heart. The FP also failed to send the patient to an emergency department when she complained of shortness of breath on exertion.
THE DEFENSE An urgent cardiac work-up was not indicated and the patient’s cholesterol levels were only mildly elevated and did not require medical management. Her MI was unavoidable since most infarctions are due to plaque rupture in coronary vessels that aren’t occluded enough to require treatment.
VERDICT $1.6 million Michigan verdict.
COMMENT I think the key issue in this difficult diagnostic case is not the lack of prescribing cholesterol medication, but the repeated office visits with no definite diagnosis. If the physician had escalated the evaluation more quickly, the MI might have been avoided.
Narcotic misstep has tragic consequences
A 47-YEAR-OLD MAN SOUGHT TREATMENT FOR DRUG ADDICTION. His physician prescribed methadone, despite not being licensed to do so. After 4 days of taking methadone, the patient went to the hospital because he felt dizzy and was having difficulty breathing. Two days after being examined and discharged, he died from methadone toxicity.
PLAINTIFF’S CLAIM The toxicity was caused by simultaneous use of methadone and alprazolam, which the patient also had been prescribed. The physician failed to recognize the potential toxicity and should have performed testing that could have revealed the simultaneous use of other drugs. In addition, the physician was not licensed to prescribe methadone.
THE DEFENSE The physician had recommended a licensed, qualified facility that could have treated the plaintiff, but the plaintiff preferred treatment in a setting that allowed him to remain anonymous.
VERDICT $1.15 million New York settlement.
COMMENT Don’t break the law, even if your patient asks you to. Know your state laws regarding narcotic prescribing. These are getting more stringent due to the rapid rise in prescription narcotic overdose deaths in the United States.
Inadequate evaluation of a mole has costly consequences
Inadequate evaluation of a mole has costly consequences
A 53-year-old woman went to her physician for treatment of a mole on her upper right arm, which she stated had grown and changed color. The physician burned it off without conducting a biopsy or follow-up. Fifteen months later, the patient returned to her physician because the scar was raised with small bumps. He referred her to a surgeon, who diagnosed malignant melanoma (Clark’s level V), with a satellite lesion but negative lymph nodes. The patient underwent surgery and adjuvant interferon-alpha therapy, which caused significant adverse effects.
The patient now has anxiety related to fears of recurrence or death, and must undergo regular positron emission tomography and computed tomography scans to evaluate her for recurrence.
PLAINTIFF’S CLAIM The melanoma should have been diagnosed at the patient’s initial presentation. If it had been diagnosed at that time, the patient would have had an 85% to 90% chance of survival, but because it wasn’t, her survival rate dropped to 60%.
THE DEFENSE No information about the defense is available.
VERDICT $750,000 Virginia settlement.
COMMENT When there is any doubt—by patient or physician—cut it out and send it out (for biopsy).
A higher index of suspicion for PE could have been lifesaving
A 37-year-old morbidly obese man was recovering in a rehabilitation facility from spinal surgery performed 2 weeks earlier. On the day he was to be discharged, he was transported by ambulance to the emergency department (ED) complaining of “a syncopal episode” with weakness, lightheadedness, dizziness, and sweatiness. This was followed by a second episode with similar symptoms. The patient had no wheezes or rales and his heart rhythm was normal, with no murmurs or gallop. In the ED his pulse rose from 94 to 116 and his blood pressure (BP) rose from 106/82 to 145/102. An electrocardiogram (EKG) was abnormal.
The ED physician felt that the likelihood of pulmonary embolism (PE) was low; he suspected, instead, that it was “likely vagal syncope.” The patient returned to the rehab facility, stayed overnight, and was discharged the next day. Two days later, he became short of breath, passed out, and was taken by ambulance to the hospital, where resuscitation efforts were unsuccessful. Autopsy revealed the cause of death was pulmonary thromboemboli from deep vein thrombosis.
PLAINTIFF’S CLAIM The ED physician failed to rule out PE, which should have been considered because of the patient’s obesity, recent back surgery, immobilization, syncope, tachycardia, elevated BP, and abnormal EKG.
THE DEFENSE No information about the defense is available.
VERDICT $1.25 million Massachusetts settlement.
COMMENT Why the physician decided that this patient, who died of a PE, was at low risk for one is puzzling. I count at least 4 risk factors for PE: obesity, postoperative status, abnormal EKG, and tachycardia.
Inadequate evaluation of a mole has costly consequences
A 53-year-old woman went to her physician for treatment of a mole on her upper right arm, which she stated had grown and changed color. The physician burned it off without conducting a biopsy or follow-up. Fifteen months later, the patient returned to her physician because the scar was raised with small bumps. He referred her to a surgeon, who diagnosed malignant melanoma (Clark’s level V), with a satellite lesion but negative lymph nodes. The patient underwent surgery and adjuvant interferon-alpha therapy, which caused significant adverse effects.
The patient now has anxiety related to fears of recurrence or death, and must undergo regular positron emission tomography and computed tomography scans to evaluate her for recurrence.
PLAINTIFF’S CLAIM The melanoma should have been diagnosed at the patient’s initial presentation. If it had been diagnosed at that time, the patient would have had an 85% to 90% chance of survival, but because it wasn’t, her survival rate dropped to 60%.
THE DEFENSE No information about the defense is available.
VERDICT $750,000 Virginia settlement.
COMMENT When there is any doubt—by patient or physician—cut it out and send it out (for biopsy).
A higher index of suspicion for PE could have been lifesaving
A 37-year-old morbidly obese man was recovering in a rehabilitation facility from spinal surgery performed 2 weeks earlier. On the day he was to be discharged, he was transported by ambulance to the emergency department (ED) complaining of “a syncopal episode” with weakness, lightheadedness, dizziness, and sweatiness. This was followed by a second episode with similar symptoms. The patient had no wheezes or rales and his heart rhythm was normal, with no murmurs or gallop. In the ED his pulse rose from 94 to 116 and his blood pressure (BP) rose from 106/82 to 145/102. An electrocardiogram (EKG) was abnormal.
The ED physician felt that the likelihood of pulmonary embolism (PE) was low; he suspected, instead, that it was “likely vagal syncope.” The patient returned to the rehab facility, stayed overnight, and was discharged the next day. Two days later, he became short of breath, passed out, and was taken by ambulance to the hospital, where resuscitation efforts were unsuccessful. Autopsy revealed the cause of death was pulmonary thromboemboli from deep vein thrombosis.
PLAINTIFF’S CLAIM The ED physician failed to rule out PE, which should have been considered because of the patient’s obesity, recent back surgery, immobilization, syncope, tachycardia, elevated BP, and abnormal EKG.
THE DEFENSE No information about the defense is available.
VERDICT $1.25 million Massachusetts settlement.
COMMENT Why the physician decided that this patient, who died of a PE, was at low risk for one is puzzling. I count at least 4 risk factors for PE: obesity, postoperative status, abnormal EKG, and tachycardia.
Inadequate evaluation of a mole has costly consequences
A 53-year-old woman went to her physician for treatment of a mole on her upper right arm, which she stated had grown and changed color. The physician burned it off without conducting a biopsy or follow-up. Fifteen months later, the patient returned to her physician because the scar was raised with small bumps. He referred her to a surgeon, who diagnosed malignant melanoma (Clark’s level V), with a satellite lesion but negative lymph nodes. The patient underwent surgery and adjuvant interferon-alpha therapy, which caused significant adverse effects.
The patient now has anxiety related to fears of recurrence or death, and must undergo regular positron emission tomography and computed tomography scans to evaluate her for recurrence.
PLAINTIFF’S CLAIM The melanoma should have been diagnosed at the patient’s initial presentation. If it had been diagnosed at that time, the patient would have had an 85% to 90% chance of survival, but because it wasn’t, her survival rate dropped to 60%.
THE DEFENSE No information about the defense is available.
VERDICT $750,000 Virginia settlement.
COMMENT When there is any doubt—by patient or physician—cut it out and send it out (for biopsy).
A higher index of suspicion for PE could have been lifesaving
A 37-year-old morbidly obese man was recovering in a rehabilitation facility from spinal surgery performed 2 weeks earlier. On the day he was to be discharged, he was transported by ambulance to the emergency department (ED) complaining of “a syncopal episode” with weakness, lightheadedness, dizziness, and sweatiness. This was followed by a second episode with similar symptoms. The patient had no wheezes or rales and his heart rhythm was normal, with no murmurs or gallop. In the ED his pulse rose from 94 to 116 and his blood pressure (BP) rose from 106/82 to 145/102. An electrocardiogram (EKG) was abnormal.
The ED physician felt that the likelihood of pulmonary embolism (PE) was low; he suspected, instead, that it was “likely vagal syncope.” The patient returned to the rehab facility, stayed overnight, and was discharged the next day. Two days later, he became short of breath, passed out, and was taken by ambulance to the hospital, where resuscitation efforts were unsuccessful. Autopsy revealed the cause of death was pulmonary thromboemboli from deep vein thrombosis.
PLAINTIFF’S CLAIM The ED physician failed to rule out PE, which should have been considered because of the patient’s obesity, recent back surgery, immobilization, syncope, tachycardia, elevated BP, and abnormal EKG.
THE DEFENSE No information about the defense is available.
VERDICT $1.25 million Massachusetts settlement.
COMMENT Why the physician decided that this patient, who died of a PE, was at low risk for one is puzzling. I count at least 4 risk factors for PE: obesity, postoperative status, abnormal EKG, and tachycardia.
Premature infant has CP: $14.5M verdict
Premature infant has CP: $14.5M verdict
After learning that, 14 years earlier, a 36-year-old woman had undergone an emergency cesarean delivery at 32 weeks’ gestation, her health-care providers planned a cesarean delivery for the new pregnancy. The woman was admitted to the hospital in preterm labor. Three days later, she was discharged, but readmitted twice more over a 2-week period. At each admission, preterm labor was halted using medication and bed rest.
The patient’s water broke and she was admitted to the hospital at 25 weeks’ gestation, about a week after the previous admission. Shortly after admission, the patient asked about a cesarean delivery, but no action was taken. When her ObGyn arrived at the hospital 5 hours later, the patient asked for a cesarean delivery; the ObGyn said he wanted to wait to see how her labor was progressing. After 3 hours, the fetus showed signs of distress, and an emergency cesarean delivery was undertaken. The infant experienced a massive brain hemorrhage, resulting in cerebral palsy (CP). The child has cognitive delays, visual impairment, and additional problems; he will require lifelong care.
PARENTS’ CLAIM The ObGyn and hospital were negligent in discharging the woman from admission for preterm labor. Cesarean delivery should have been performed much earlier due to nonreassuring fetal heart tones. Severe variable decelerations caused cerebral blood flow fluctuations that led to the hemorrhage.
DEFENDANTS’ DEFENSE The child’s prematurity and a severe placental infection led to the injuries. Nothing would have changed the outcome.
VERDICT A $14.5 million Ohio verdict was returned, including $1.5 million for the mother.
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Costs returned afterverdict for the defense
A 65-year-old woman underwent a hysterectomy for treatment of uterine cancer performed by a gynecologic oncologist. Postoperatively, the patient developed an infection. A small-bowel injury was surgically repaired. The patient was hospitalized for 4 months for treatment of sepsis.
PARENTS’ CLAIM The physician was negligent for injuring the patient’s bowel and then failing to identify and repair the injury during surgery.
PHYSICIAN’S DEFENSE There was no negligence. The patient had significant adhesions from prior surgeries. The physician noted minor serosal tears of the bowel, several of which were repaired during surgery. He checked the length of the bowel for tears/perforations several times during the procedure, but found none. The patient had areas of weakness in her bowel, one of which broke down after surgery. The perforation was repaired in a timely manner.
VERDICT A Michigan defense verdict was returned. The physician was awarded $14,535 in costs.
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Colon injury after cystectomy
A 21-year-old woman underwent laparoscopic ovarian cystectomy, performed by her gynecologist, and was discharged the next day. Eight days later, the patient went to the emergency department (ED) with pelvic pain. Testing revealed a perforated colon with peritonitis. She underwent repair by laparotomy, including bowel resection and colostomy, which was reversed several months later. She has not regained regular bowel function, cannot digest food that has not been finely sliced, and constantly uses laxatives.
PARENTS’ CLAIM The colon injury occurred during cystectomy because the gynecologist was negligent in failing to maintain proper anatomical landmarks. The injury should have been recognized at the time of surgery by injecting saline solution into the colon. She had not been informed of the risk of colon injury.
DEFENDANTS’ DEFENSE Colon injury is a known complication of cystectomy. The injury could have occurred after surgery due to a minor nick of the colon that was undetectable during surgery. Proper informed consent was acquired.
VERDICT A $340,000 New York settlement was reached.
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Mother hemorrhages, dies after delivery: $1M settlement
A 19-year-old woman presented at full term to a community hospital. After several hours of labor, an emergency cesarean delivery was performed due to arrested descent.
Fifteen minutes after delivery, the mother exhibited moderate bleeding with decreasing blood pressure and tachycardia. The post-anesthesia care unit nurse assessed the patient’s uterus as “boggy,” and alerted the ObGyn, who immediately reacted by expressing clots from the uterus. He noted that the fundus was firm. He ordered intravenous (IV) oxytocin, but the patient continued to hemorrhage. Fifteen minutes later, the patient’s vital signs worsened. The ObGyn ordered blood products, uterotonics, and an additional IV line for fluid resuscitation. He began to massage the fundus and expressed clots.
When the patient did not stabilize, she was returned to the OR. After attempting to stop the bleeding with O’Leary stitches, the ObGyn performed a hysterectomy. Six hours after surgery, and after transfusion of a total of 12 units of blood, the woman coded multiple times. She died 14 hours after delivery. Cause of death was disseminated intravascular coagulopathy caused by an atonic uterus.
ESTATE’S CLAIM The ObGyn failed to recognize the extent of the postpartum hemorrhage and should have acted more aggressively with resuscitation. He should have returned her to the OR earlier. The ObGyn was negligent in waiting 45 minutes for cross-matched blood rather than using universal donor O-negative blood that was readily available.
PHYSICIAN’S DEFENSE The ObGyn denied negligence and maintained that he had acted properly. He returned the patient to the OR within 90 minutes of first learning of the hemorrhage.
VERDICT A $1 million Virginia settlement was reached.
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Infant born with broken arms, collarbone, facial bones
A 23-year-old woman had gestational diabetes. She is 5’9” tall and weighed 300 lb while pregnant. She went to the hospital in labor.
During delivery, shoulder dystocia was encountered. The ObGyn performed a variety of techniques, including the McRobert’s maneuver. Forceps were eventually used for delivery.
Both of the newborn’s arms were broken, and she had a broken collarbone and facial fractures. The mother also suffered significant vaginal lacerations and required an episiotomy. She continues to complain of bladder and bowel problems.
PARENTS’ CLAIM A vaginal delivery should not have been attempted due to the mother’s gestational diabetes and the risk of having a macrosomic baby. A cesarean delivery should have been performed. The ObGyn did not use the proper techniques when delivering the child after shoulder dystocia was encountered.
PHYSICIAN’S DEFENSE The ObGyn denied negligence. He claimed that the baby recovered well from her injuries. The mother underwent surgery and now has excellent bladder and bowel control.
VERDICT A confidential Louisiana settlement was reached with the hospital before trial. A defense verdict was returned for the ObGyn.
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Protein found in urine at 39 weeks’ gestation: mother and child die
At 39 weeks' gestation, a woman saw her ObGyn for a prenatal visit. During the examination, the ObGyn found high levels of protein in the woman’s urine, an accumulation of fluid in her ankles, and the highest blood pressure (BP) reading of the woman’s pregnancy. However, because the BP reading was lower than that required to diagnose preeclampsia, the ObGyn sent the patient home and scheduled the next prenatal visit for the following week. The woman and her unborn child died 5 days later.
ESTATE’S CLAIM The ObGyn was negligent in failing to order a urine study and more closely monitor the mother’s symptoms when signs of preeclampsia were evident at 39 weeks’ gestation. Delivery of the child would have resolved the problem and saved both lives.
PHYSICIAN’S DEFENSE The case was settled during the trial.
VERDICT A $3 million Illinois settlement was reached.
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Baby dies from group B strep
A 16-year-old woman planned delivery at a local hospital. Her ObGyn’s practice regularly sends the hospital its patients’ prenatal records, starting at 25 weeks’ gestation. At 33 weeks, the ObGyn took a vaginal culture to test for group B Streptococcus (GBS) bacteria. The laboratory reported positive GBS results to a computer in the ObGyn’s office, but the results were not entered into the patient’s chart.
The mother went to the ED in labor a week later; she was evaluated and discharged. Several days later, she returned to the ED, but was again discharged. She returned the next day, now in gestational week 36. An on-call ObGyn admitted her. A labor and delivery nurse claimed that the ObGyn’s office reported that the mother was GBS negative, so the nurse placed a negative sign in the prenatal record in the chart. When the patient’s ObGyn arrived at the hospital, he noticed the negative sign in the chart.
At birth, the baby’s Apgar scores were 7 at 1 minute and 7 at 5 minutes. She appeared limp and was grunting. A pediatrician diagnosed transient respiratory problems related to prematurity. The baby continued to deteriorate; antibiotics were ordered 7 hours after birth. After the child was transported to another facility, she died. The cause of death was GBS sepsis and pneumonia.
PARENTS’ CLAIM The ObGyn was negligent in failing to properly and timely note the positive GBS test result in the mother’s chart. The ObGyn’s office staff was negligent in miscommunicating the GBS status to the nurse.
DEFENDANTS’ DEFENSE The ObGyn usually noted laboratory results at the next prenatal visit, but the mother gave birth before that occurred. The on-call ObGyn failed to give antibiotics when the mother presented in preterm labor with unknown GBS status. The hospital did not have a protocol that required the on-call ObGyn to prescribe prophylactic antibiotics in this context. The nurse was negligent for failing to verify the oral telephone report of GBS-negative status with a written or faxed laboratory report.
The ObGyn surmised that the infection had occurred in utero, not during birth; antibiotics would not have changed the outcome.
VERDICT The parents settled with the hospital for a confidential amount. An Arizona defense verdict was returned for the ObGyn.
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Child has quadraparetic CP after oxytocin-augmented delivery
A pregnant woman was hospitalized for 23-hour observation with blood work and obstetric ultrasonography. The admitting nurse noted that the patient was having mild contractions and that fetal heart tones were 130 bpm with moderate variability. The mother’s cervix was dilated to 2.5 cm, 70% effaced, at –1 station, with intact and bulging membranes and normal maternal vital signs. The ObGyn ordered intravenous ampicillin and sent the mother to labor and delivery. He prescribed oxytocin (6 mU/min), but, after its initiation, oxytocin was discontinued for almost 2 hours. When the mother had five contractions in 10 minutes, oxytocin was restarted at 8 mU/min. The oxytocin dosage was later increased to 10 mU/min, and then to 12 mU/min.
When shoulder dystocia was encountered, various maneuvers were performed. The baby was delivered using vacuum extraction. The newborn was immediately sent to the neonatal intensive care unit (NICU) with a suspected humerus fracture and poor respiration. Mechanical ventilation and treatment for hypoperfusion were initiated. She had persistently low Apgar scores, intracranial hemorrhaging, seizures, severe metabolic acidosis, and hypoxic ischemic encephalopathy. She has quadraparetic cerebral palsy with related disabilities.
PARENTS’ CLAIM The ObGyn and hospital were negligent in the treatment of the mother during labor and delivery, causing the child to be born with serious injuries.
DEFENDANTS’ DEFENSE The case was settled during the trial.
VERDICT A $4,250,000 Texas settlement was reached, including $75,000 for the parents, and the remainder placed into a trust for the child.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
Premature infant has CP: $14.5M verdict
After learning that, 14 years earlier, a 36-year-old woman had undergone an emergency cesarean delivery at 32 weeks’ gestation, her health-care providers planned a cesarean delivery for the new pregnancy. The woman was admitted to the hospital in preterm labor. Three days later, she was discharged, but readmitted twice more over a 2-week period. At each admission, preterm labor was halted using medication and bed rest.
The patient’s water broke and she was admitted to the hospital at 25 weeks’ gestation, about a week after the previous admission. Shortly after admission, the patient asked about a cesarean delivery, but no action was taken. When her ObGyn arrived at the hospital 5 hours later, the patient asked for a cesarean delivery; the ObGyn said he wanted to wait to see how her labor was progressing. After 3 hours, the fetus showed signs of distress, and an emergency cesarean delivery was undertaken. The infant experienced a massive brain hemorrhage, resulting in cerebral palsy (CP). The child has cognitive delays, visual impairment, and additional problems; he will require lifelong care.
PARENTS’ CLAIM The ObGyn and hospital were negligent in discharging the woman from admission for preterm labor. Cesarean delivery should have been performed much earlier due to nonreassuring fetal heart tones. Severe variable decelerations caused cerebral blood flow fluctuations that led to the hemorrhage.
DEFENDANTS’ DEFENSE The child’s prematurity and a severe placental infection led to the injuries. Nothing would have changed the outcome.
VERDICT A $14.5 million Ohio verdict was returned, including $1.5 million for the mother.
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Costs returned afterverdict for the defense
A 65-year-old woman underwent a hysterectomy for treatment of uterine cancer performed by a gynecologic oncologist. Postoperatively, the patient developed an infection. A small-bowel injury was surgically repaired. The patient was hospitalized for 4 months for treatment of sepsis.
PARENTS’ CLAIM The physician was negligent for injuring the patient’s bowel and then failing to identify and repair the injury during surgery.
PHYSICIAN’S DEFENSE There was no negligence. The patient had significant adhesions from prior surgeries. The physician noted minor serosal tears of the bowel, several of which were repaired during surgery. He checked the length of the bowel for tears/perforations several times during the procedure, but found none. The patient had areas of weakness in her bowel, one of which broke down after surgery. The perforation was repaired in a timely manner.
VERDICT A Michigan defense verdict was returned. The physician was awarded $14,535 in costs.
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Colon injury after cystectomy
A 21-year-old woman underwent laparoscopic ovarian cystectomy, performed by her gynecologist, and was discharged the next day. Eight days later, the patient went to the emergency department (ED) with pelvic pain. Testing revealed a perforated colon with peritonitis. She underwent repair by laparotomy, including bowel resection and colostomy, which was reversed several months later. She has not regained regular bowel function, cannot digest food that has not been finely sliced, and constantly uses laxatives.
PARENTS’ CLAIM The colon injury occurred during cystectomy because the gynecologist was negligent in failing to maintain proper anatomical landmarks. The injury should have been recognized at the time of surgery by injecting saline solution into the colon. She had not been informed of the risk of colon injury.
DEFENDANTS’ DEFENSE Colon injury is a known complication of cystectomy. The injury could have occurred after surgery due to a minor nick of the colon that was undetectable during surgery. Proper informed consent was acquired.
VERDICT A $340,000 New York settlement was reached.
_______________
Mother hemorrhages, dies after delivery: $1M settlement
A 19-year-old woman presented at full term to a community hospital. After several hours of labor, an emergency cesarean delivery was performed due to arrested descent.
Fifteen minutes after delivery, the mother exhibited moderate bleeding with decreasing blood pressure and tachycardia. The post-anesthesia care unit nurse assessed the patient’s uterus as “boggy,” and alerted the ObGyn, who immediately reacted by expressing clots from the uterus. He noted that the fundus was firm. He ordered intravenous (IV) oxytocin, but the patient continued to hemorrhage. Fifteen minutes later, the patient’s vital signs worsened. The ObGyn ordered blood products, uterotonics, and an additional IV line for fluid resuscitation. He began to massage the fundus and expressed clots.
When the patient did not stabilize, she was returned to the OR. After attempting to stop the bleeding with O’Leary stitches, the ObGyn performed a hysterectomy. Six hours after surgery, and after transfusion of a total of 12 units of blood, the woman coded multiple times. She died 14 hours after delivery. Cause of death was disseminated intravascular coagulopathy caused by an atonic uterus.
ESTATE’S CLAIM The ObGyn failed to recognize the extent of the postpartum hemorrhage and should have acted more aggressively with resuscitation. He should have returned her to the OR earlier. The ObGyn was negligent in waiting 45 minutes for cross-matched blood rather than using universal donor O-negative blood that was readily available.
PHYSICIAN’S DEFENSE The ObGyn denied negligence and maintained that he had acted properly. He returned the patient to the OR within 90 minutes of first learning of the hemorrhage.
VERDICT A $1 million Virginia settlement was reached.
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Infant born with broken arms, collarbone, facial bones
A 23-year-old woman had gestational diabetes. She is 5’9” tall and weighed 300 lb while pregnant. She went to the hospital in labor.
During delivery, shoulder dystocia was encountered. The ObGyn performed a variety of techniques, including the McRobert’s maneuver. Forceps were eventually used for delivery.
Both of the newborn’s arms were broken, and she had a broken collarbone and facial fractures. The mother also suffered significant vaginal lacerations and required an episiotomy. She continues to complain of bladder and bowel problems.
PARENTS’ CLAIM A vaginal delivery should not have been attempted due to the mother’s gestational diabetes and the risk of having a macrosomic baby. A cesarean delivery should have been performed. The ObGyn did not use the proper techniques when delivering the child after shoulder dystocia was encountered.
PHYSICIAN’S DEFENSE The ObGyn denied negligence. He claimed that the baby recovered well from her injuries. The mother underwent surgery and now has excellent bladder and bowel control.
VERDICT A confidential Louisiana settlement was reached with the hospital before trial. A defense verdict was returned for the ObGyn.
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Protein found in urine at 39 weeks’ gestation: mother and child die
At 39 weeks' gestation, a woman saw her ObGyn for a prenatal visit. During the examination, the ObGyn found high levels of protein in the woman’s urine, an accumulation of fluid in her ankles, and the highest blood pressure (BP) reading of the woman’s pregnancy. However, because the BP reading was lower than that required to diagnose preeclampsia, the ObGyn sent the patient home and scheduled the next prenatal visit for the following week. The woman and her unborn child died 5 days later.
ESTATE’S CLAIM The ObGyn was negligent in failing to order a urine study and more closely monitor the mother’s symptoms when signs of preeclampsia were evident at 39 weeks’ gestation. Delivery of the child would have resolved the problem and saved both lives.
PHYSICIAN’S DEFENSE The case was settled during the trial.
VERDICT A $3 million Illinois settlement was reached.
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Baby dies from group B strep
A 16-year-old woman planned delivery at a local hospital. Her ObGyn’s practice regularly sends the hospital its patients’ prenatal records, starting at 25 weeks’ gestation. At 33 weeks, the ObGyn took a vaginal culture to test for group B Streptococcus (GBS) bacteria. The laboratory reported positive GBS results to a computer in the ObGyn’s office, but the results were not entered into the patient’s chart.
The mother went to the ED in labor a week later; she was evaluated and discharged. Several days later, she returned to the ED, but was again discharged. She returned the next day, now in gestational week 36. An on-call ObGyn admitted her. A labor and delivery nurse claimed that the ObGyn’s office reported that the mother was GBS negative, so the nurse placed a negative sign in the prenatal record in the chart. When the patient’s ObGyn arrived at the hospital, he noticed the negative sign in the chart.
At birth, the baby’s Apgar scores were 7 at 1 minute and 7 at 5 minutes. She appeared limp and was grunting. A pediatrician diagnosed transient respiratory problems related to prematurity. The baby continued to deteriorate; antibiotics were ordered 7 hours after birth. After the child was transported to another facility, she died. The cause of death was GBS sepsis and pneumonia.
PARENTS’ CLAIM The ObGyn was negligent in failing to properly and timely note the positive GBS test result in the mother’s chart. The ObGyn’s office staff was negligent in miscommunicating the GBS status to the nurse.
DEFENDANTS’ DEFENSE The ObGyn usually noted laboratory results at the next prenatal visit, but the mother gave birth before that occurred. The on-call ObGyn failed to give antibiotics when the mother presented in preterm labor with unknown GBS status. The hospital did not have a protocol that required the on-call ObGyn to prescribe prophylactic antibiotics in this context. The nurse was negligent for failing to verify the oral telephone report of GBS-negative status with a written or faxed laboratory report.
The ObGyn surmised that the infection had occurred in utero, not during birth; antibiotics would not have changed the outcome.
VERDICT The parents settled with the hospital for a confidential amount. An Arizona defense verdict was returned for the ObGyn.
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Child has quadraparetic CP after oxytocin-augmented delivery
A pregnant woman was hospitalized for 23-hour observation with blood work and obstetric ultrasonography. The admitting nurse noted that the patient was having mild contractions and that fetal heart tones were 130 bpm with moderate variability. The mother’s cervix was dilated to 2.5 cm, 70% effaced, at –1 station, with intact and bulging membranes and normal maternal vital signs. The ObGyn ordered intravenous ampicillin and sent the mother to labor and delivery. He prescribed oxytocin (6 mU/min), but, after its initiation, oxytocin was discontinued for almost 2 hours. When the mother had five contractions in 10 minutes, oxytocin was restarted at 8 mU/min. The oxytocin dosage was later increased to 10 mU/min, and then to 12 mU/min.
When shoulder dystocia was encountered, various maneuvers were performed. The baby was delivered using vacuum extraction. The newborn was immediately sent to the neonatal intensive care unit (NICU) with a suspected humerus fracture and poor respiration. Mechanical ventilation and treatment for hypoperfusion were initiated. She had persistently low Apgar scores, intracranial hemorrhaging, seizures, severe metabolic acidosis, and hypoxic ischemic encephalopathy. She has quadraparetic cerebral palsy with related disabilities.
PARENTS’ CLAIM The ObGyn and hospital were negligent in the treatment of the mother during labor and delivery, causing the child to be born with serious injuries.
DEFENDANTS’ DEFENSE The case was settled during the trial.
VERDICT A $4,250,000 Texas settlement was reached, including $75,000 for the parents, and the remainder placed into a trust for the child.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
Premature infant has CP: $14.5M verdict
After learning that, 14 years earlier, a 36-year-old woman had undergone an emergency cesarean delivery at 32 weeks’ gestation, her health-care providers planned a cesarean delivery for the new pregnancy. The woman was admitted to the hospital in preterm labor. Three days later, she was discharged, but readmitted twice more over a 2-week period. At each admission, preterm labor was halted using medication and bed rest.
The patient’s water broke and she was admitted to the hospital at 25 weeks’ gestation, about a week after the previous admission. Shortly after admission, the patient asked about a cesarean delivery, but no action was taken. When her ObGyn arrived at the hospital 5 hours later, the patient asked for a cesarean delivery; the ObGyn said he wanted to wait to see how her labor was progressing. After 3 hours, the fetus showed signs of distress, and an emergency cesarean delivery was undertaken. The infant experienced a massive brain hemorrhage, resulting in cerebral palsy (CP). The child has cognitive delays, visual impairment, and additional problems; he will require lifelong care.
PARENTS’ CLAIM The ObGyn and hospital were negligent in discharging the woman from admission for preterm labor. Cesarean delivery should have been performed much earlier due to nonreassuring fetal heart tones. Severe variable decelerations caused cerebral blood flow fluctuations that led to the hemorrhage.
DEFENDANTS’ DEFENSE The child’s prematurity and a severe placental infection led to the injuries. Nothing would have changed the outcome.
VERDICT A $14.5 million Ohio verdict was returned, including $1.5 million for the mother.
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Costs returned afterverdict for the defense
A 65-year-old woman underwent a hysterectomy for treatment of uterine cancer performed by a gynecologic oncologist. Postoperatively, the patient developed an infection. A small-bowel injury was surgically repaired. The patient was hospitalized for 4 months for treatment of sepsis.
PARENTS’ CLAIM The physician was negligent for injuring the patient’s bowel and then failing to identify and repair the injury during surgery.
PHYSICIAN’S DEFENSE There was no negligence. The patient had significant adhesions from prior surgeries. The physician noted minor serosal tears of the bowel, several of which were repaired during surgery. He checked the length of the bowel for tears/perforations several times during the procedure, but found none. The patient had areas of weakness in her bowel, one of which broke down after surgery. The perforation was repaired in a timely manner.
VERDICT A Michigan defense verdict was returned. The physician was awarded $14,535 in costs.
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Colon injury after cystectomy
A 21-year-old woman underwent laparoscopic ovarian cystectomy, performed by her gynecologist, and was discharged the next day. Eight days later, the patient went to the emergency department (ED) with pelvic pain. Testing revealed a perforated colon with peritonitis. She underwent repair by laparotomy, including bowel resection and colostomy, which was reversed several months later. She has not regained regular bowel function, cannot digest food that has not been finely sliced, and constantly uses laxatives.
PARENTS’ CLAIM The colon injury occurred during cystectomy because the gynecologist was negligent in failing to maintain proper anatomical landmarks. The injury should have been recognized at the time of surgery by injecting saline solution into the colon. She had not been informed of the risk of colon injury.
DEFENDANTS’ DEFENSE Colon injury is a known complication of cystectomy. The injury could have occurred after surgery due to a minor nick of the colon that was undetectable during surgery. Proper informed consent was acquired.
VERDICT A $340,000 New York settlement was reached.
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Mother hemorrhages, dies after delivery: $1M settlement
A 19-year-old woman presented at full term to a community hospital. After several hours of labor, an emergency cesarean delivery was performed due to arrested descent.
Fifteen minutes after delivery, the mother exhibited moderate bleeding with decreasing blood pressure and tachycardia. The post-anesthesia care unit nurse assessed the patient’s uterus as “boggy,” and alerted the ObGyn, who immediately reacted by expressing clots from the uterus. He noted that the fundus was firm. He ordered intravenous (IV) oxytocin, but the patient continued to hemorrhage. Fifteen minutes later, the patient’s vital signs worsened. The ObGyn ordered blood products, uterotonics, and an additional IV line for fluid resuscitation. He began to massage the fundus and expressed clots.
When the patient did not stabilize, she was returned to the OR. After attempting to stop the bleeding with O’Leary stitches, the ObGyn performed a hysterectomy. Six hours after surgery, and after transfusion of a total of 12 units of blood, the woman coded multiple times. She died 14 hours after delivery. Cause of death was disseminated intravascular coagulopathy caused by an atonic uterus.
ESTATE’S CLAIM The ObGyn failed to recognize the extent of the postpartum hemorrhage and should have acted more aggressively with resuscitation. He should have returned her to the OR earlier. The ObGyn was negligent in waiting 45 minutes for cross-matched blood rather than using universal donor O-negative blood that was readily available.
PHYSICIAN’S DEFENSE The ObGyn denied negligence and maintained that he had acted properly. He returned the patient to the OR within 90 minutes of first learning of the hemorrhage.
VERDICT A $1 million Virginia settlement was reached.
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Infant born with broken arms, collarbone, facial bones
A 23-year-old woman had gestational diabetes. She is 5’9” tall and weighed 300 lb while pregnant. She went to the hospital in labor.
During delivery, shoulder dystocia was encountered. The ObGyn performed a variety of techniques, including the McRobert’s maneuver. Forceps were eventually used for delivery.
Both of the newborn’s arms were broken, and she had a broken collarbone and facial fractures. The mother also suffered significant vaginal lacerations and required an episiotomy. She continues to complain of bladder and bowel problems.
PARENTS’ CLAIM A vaginal delivery should not have been attempted due to the mother’s gestational diabetes and the risk of having a macrosomic baby. A cesarean delivery should have been performed. The ObGyn did not use the proper techniques when delivering the child after shoulder dystocia was encountered.
PHYSICIAN’S DEFENSE The ObGyn denied negligence. He claimed that the baby recovered well from her injuries. The mother underwent surgery and now has excellent bladder and bowel control.
VERDICT A confidential Louisiana settlement was reached with the hospital before trial. A defense verdict was returned for the ObGyn.
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Protein found in urine at 39 weeks’ gestation: mother and child die
At 39 weeks' gestation, a woman saw her ObGyn for a prenatal visit. During the examination, the ObGyn found high levels of protein in the woman’s urine, an accumulation of fluid in her ankles, and the highest blood pressure (BP) reading of the woman’s pregnancy. However, because the BP reading was lower than that required to diagnose preeclampsia, the ObGyn sent the patient home and scheduled the next prenatal visit for the following week. The woman and her unborn child died 5 days later.
ESTATE’S CLAIM The ObGyn was negligent in failing to order a urine study and more closely monitor the mother’s symptoms when signs of preeclampsia were evident at 39 weeks’ gestation. Delivery of the child would have resolved the problem and saved both lives.
PHYSICIAN’S DEFENSE The case was settled during the trial.
VERDICT A $3 million Illinois settlement was reached.
_______________
Baby dies from group B strep
A 16-year-old woman planned delivery at a local hospital. Her ObGyn’s practice regularly sends the hospital its patients’ prenatal records, starting at 25 weeks’ gestation. At 33 weeks, the ObGyn took a vaginal culture to test for group B Streptococcus (GBS) bacteria. The laboratory reported positive GBS results to a computer in the ObGyn’s office, but the results were not entered into the patient’s chart.
The mother went to the ED in labor a week later; she was evaluated and discharged. Several days later, she returned to the ED, but was again discharged. She returned the next day, now in gestational week 36. An on-call ObGyn admitted her. A labor and delivery nurse claimed that the ObGyn’s office reported that the mother was GBS negative, so the nurse placed a negative sign in the prenatal record in the chart. When the patient’s ObGyn arrived at the hospital, he noticed the negative sign in the chart.
At birth, the baby’s Apgar scores were 7 at 1 minute and 7 at 5 minutes. She appeared limp and was grunting. A pediatrician diagnosed transient respiratory problems related to prematurity. The baby continued to deteriorate; antibiotics were ordered 7 hours after birth. After the child was transported to another facility, she died. The cause of death was GBS sepsis and pneumonia.
PARENTS’ CLAIM The ObGyn was negligent in failing to properly and timely note the positive GBS test result in the mother’s chart. The ObGyn’s office staff was negligent in miscommunicating the GBS status to the nurse.
DEFENDANTS’ DEFENSE The ObGyn usually noted laboratory results at the next prenatal visit, but the mother gave birth before that occurred. The on-call ObGyn failed to give antibiotics when the mother presented in preterm labor with unknown GBS status. The hospital did not have a protocol that required the on-call ObGyn to prescribe prophylactic antibiotics in this context. The nurse was negligent for failing to verify the oral telephone report of GBS-negative status with a written or faxed laboratory report.
The ObGyn surmised that the infection had occurred in utero, not during birth; antibiotics would not have changed the outcome.
VERDICT The parents settled with the hospital for a confidential amount. An Arizona defense verdict was returned for the ObGyn.
_______________
Child has quadraparetic CP after oxytocin-augmented delivery
A pregnant woman was hospitalized for 23-hour observation with blood work and obstetric ultrasonography. The admitting nurse noted that the patient was having mild contractions and that fetal heart tones were 130 bpm with moderate variability. The mother’s cervix was dilated to 2.5 cm, 70% effaced, at –1 station, with intact and bulging membranes and normal maternal vital signs. The ObGyn ordered intravenous ampicillin and sent the mother to labor and delivery. He prescribed oxytocin (6 mU/min), but, after its initiation, oxytocin was discontinued for almost 2 hours. When the mother had five contractions in 10 minutes, oxytocin was restarted at 8 mU/min. The oxytocin dosage was later increased to 10 mU/min, and then to 12 mU/min.
When shoulder dystocia was encountered, various maneuvers were performed. The baby was delivered using vacuum extraction. The newborn was immediately sent to the neonatal intensive care unit (NICU) with a suspected humerus fracture and poor respiration. Mechanical ventilation and treatment for hypoperfusion were initiated. She had persistently low Apgar scores, intracranial hemorrhaging, seizures, severe metabolic acidosis, and hypoxic ischemic encephalopathy. She has quadraparetic cerebral palsy with related disabilities.
PARENTS’ CLAIM The ObGyn and hospital were negligent in the treatment of the mother during labor and delivery, causing the child to be born with serious injuries.
DEFENDANTS’ DEFENSE The case was settled during the trial.
VERDICT A $4,250,000 Texas settlement was reached, including $75,000 for the parents, and the remainder placed into a trust for the child.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
Failure to properly manage a patient’s hypertension
Failure to properly manage a patient’s hypertension
A 44-YEAR-OLD MAN WHO WEIGHED >450 POUNDS went to his internist for treatment of hypertension. At a work-related physical the previous day, his blood pressure had been 160/110 mm Hg. After examination, the internist wrote a 30-day prescription for amlodipine, 5 mg/d, with 3 refills. The patient saw the physician 2 weeks later but not again until 3 months later. At that visit, the internist prescribed amlodipine, 5 mg/d, for 90 days with 2 refills. The patient missed his next appointment, which was set for 4 months later, but when his medication was about to run out, he was able to get a prescription for 10 months’ worth of amlodipine by phone. The patient died 2 months before the prescription ran out.
PLAINTIFF’S CLAIM The physician failed to properly manage and monitor the patient’s hypertension. The dosage of amlodipine was insufficient.
THE DEFENSE The patient was noncompliant and failed to show for follow-up appointments. The dosage of amlodipine was sufficient. The cause of death was unknown because no autopsy was performed.
VERDICT $136,000 New Jersey verdict.
COMMENT If we accept a patient into our practice, we need to have reasonable policies for patients to show up for follow-up, and to consider having them find another physician if they do not.
Did the patient’s age discourage proper evaluation?
THREE MONTHS AFTER NOTICING BLOOD IN HER STOOL, a 19-year-old woman went to see her physician. Without ordering a flexible sigmoidoscopy or colonoscopy, the physician diagnosed a healing anal fissure. Approximately 4 years later, the patient developed bloody diarrhea and went to a gastroenterologist, who found a 2.6 cm lesion in her rectum during a flexible sigmoidoscopy. Biopsy confirmed a low-grade adenocarcinoma. Imaging studies revealed that the cancer had spread to her lungs and liver, and she was diagnosed with Stage IV rectal cancer. After 2 years of extensive treatment that included surgical resection, conventional and experimental chemotherapy, and radiation therapy, the patient died.
PLAINTIFF’S CLAIM If the physician had ordered endoscopy exams when the patient first presented for treatment, testing could have identified a polyp or early-stage cancer.
THE DEFENSE No information about the defense is available.
VERDICT $2.5 million Maryland verdict.
COMMENT Colon cancer in a 19-year-old is extraordinarily rare. I doubt that the patient didn’t experience any more rectal bleeding until 4 years after she first sought treatment. A lesson in this tragic case is to be sure to document when you tell patients to “come back to see me right away if this happens again.”
23-year-old dies when myocarditis is mistaken for bronchitis
A 23-YEAR-OLD MAN PRESENTED TO THE EMERGENCY DEPARTMENT (ED) with chest tightness, cough, and fever. After a chest x-ray, the ED physician diagnosed bronchitis and sent the patient home with prescriptions for hydrocodone/acetaminophen and antibiotics. He was found dead in his bed less than 24 hours later. An autopsy determined the cause of death was myocarditis.
PLAINTIFF’S CLAIM The physician didn’t perform an electrocardiogram (EKG), which is a routine evaluation for a patient with chest pain. The EKG would have detected myocarditis.
THE DEFENSE The patient was evaluated properly. An EKG was not necessary.
VERDICT $2.9 million Massachusetts verdict.
COMMENT I think the jury got this one wrong. I don’t think an EKG is necessary for every case of acute bronchitis. However, I do wonder if the chest x-ray showed a large heart shadow.
Failure to properly manage a patient’s hypertension
A 44-YEAR-OLD MAN WHO WEIGHED >450 POUNDS went to his internist for treatment of hypertension. At a work-related physical the previous day, his blood pressure had been 160/110 mm Hg. After examination, the internist wrote a 30-day prescription for amlodipine, 5 mg/d, with 3 refills. The patient saw the physician 2 weeks later but not again until 3 months later. At that visit, the internist prescribed amlodipine, 5 mg/d, for 90 days with 2 refills. The patient missed his next appointment, which was set for 4 months later, but when his medication was about to run out, he was able to get a prescription for 10 months’ worth of amlodipine by phone. The patient died 2 months before the prescription ran out.
PLAINTIFF’S CLAIM The physician failed to properly manage and monitor the patient’s hypertension. The dosage of amlodipine was insufficient.
THE DEFENSE The patient was noncompliant and failed to show for follow-up appointments. The dosage of amlodipine was sufficient. The cause of death was unknown because no autopsy was performed.
VERDICT $136,000 New Jersey verdict.
COMMENT If we accept a patient into our practice, we need to have reasonable policies for patients to show up for follow-up, and to consider having them find another physician if they do not.
Did the patient’s age discourage proper evaluation?
THREE MONTHS AFTER NOTICING BLOOD IN HER STOOL, a 19-year-old woman went to see her physician. Without ordering a flexible sigmoidoscopy or colonoscopy, the physician diagnosed a healing anal fissure. Approximately 4 years later, the patient developed bloody diarrhea and went to a gastroenterologist, who found a 2.6 cm lesion in her rectum during a flexible sigmoidoscopy. Biopsy confirmed a low-grade adenocarcinoma. Imaging studies revealed that the cancer had spread to her lungs and liver, and she was diagnosed with Stage IV rectal cancer. After 2 years of extensive treatment that included surgical resection, conventional and experimental chemotherapy, and radiation therapy, the patient died.
PLAINTIFF’S CLAIM If the physician had ordered endoscopy exams when the patient first presented for treatment, testing could have identified a polyp or early-stage cancer.
THE DEFENSE No information about the defense is available.
VERDICT $2.5 million Maryland verdict.
COMMENT Colon cancer in a 19-year-old is extraordinarily rare. I doubt that the patient didn’t experience any more rectal bleeding until 4 years after she first sought treatment. A lesson in this tragic case is to be sure to document when you tell patients to “come back to see me right away if this happens again.”
23-year-old dies when myocarditis is mistaken for bronchitis
A 23-YEAR-OLD MAN PRESENTED TO THE EMERGENCY DEPARTMENT (ED) with chest tightness, cough, and fever. After a chest x-ray, the ED physician diagnosed bronchitis and sent the patient home with prescriptions for hydrocodone/acetaminophen and antibiotics. He was found dead in his bed less than 24 hours later. An autopsy determined the cause of death was myocarditis.
PLAINTIFF’S CLAIM The physician didn’t perform an electrocardiogram (EKG), which is a routine evaluation for a patient with chest pain. The EKG would have detected myocarditis.
THE DEFENSE The patient was evaluated properly. An EKG was not necessary.
VERDICT $2.9 million Massachusetts verdict.
COMMENT I think the jury got this one wrong. I don’t think an EKG is necessary for every case of acute bronchitis. However, I do wonder if the chest x-ray showed a large heart shadow.
Failure to properly manage a patient’s hypertension
A 44-YEAR-OLD MAN WHO WEIGHED >450 POUNDS went to his internist for treatment of hypertension. At a work-related physical the previous day, his blood pressure had been 160/110 mm Hg. After examination, the internist wrote a 30-day prescription for amlodipine, 5 mg/d, with 3 refills. The patient saw the physician 2 weeks later but not again until 3 months later. At that visit, the internist prescribed amlodipine, 5 mg/d, for 90 days with 2 refills. The patient missed his next appointment, which was set for 4 months later, but when his medication was about to run out, he was able to get a prescription for 10 months’ worth of amlodipine by phone. The patient died 2 months before the prescription ran out.
PLAINTIFF’S CLAIM The physician failed to properly manage and monitor the patient’s hypertension. The dosage of amlodipine was insufficient.
THE DEFENSE The patient was noncompliant and failed to show for follow-up appointments. The dosage of amlodipine was sufficient. The cause of death was unknown because no autopsy was performed.
VERDICT $136,000 New Jersey verdict.
COMMENT If we accept a patient into our practice, we need to have reasonable policies for patients to show up for follow-up, and to consider having them find another physician if they do not.
Did the patient’s age discourage proper evaluation?
THREE MONTHS AFTER NOTICING BLOOD IN HER STOOL, a 19-year-old woman went to see her physician. Without ordering a flexible sigmoidoscopy or colonoscopy, the physician diagnosed a healing anal fissure. Approximately 4 years later, the patient developed bloody diarrhea and went to a gastroenterologist, who found a 2.6 cm lesion in her rectum during a flexible sigmoidoscopy. Biopsy confirmed a low-grade adenocarcinoma. Imaging studies revealed that the cancer had spread to her lungs and liver, and she was diagnosed with Stage IV rectal cancer. After 2 years of extensive treatment that included surgical resection, conventional and experimental chemotherapy, and radiation therapy, the patient died.
PLAINTIFF’S CLAIM If the physician had ordered endoscopy exams when the patient first presented for treatment, testing could have identified a polyp or early-stage cancer.
THE DEFENSE No information about the defense is available.
VERDICT $2.5 million Maryland verdict.
COMMENT Colon cancer in a 19-year-old is extraordinarily rare. I doubt that the patient didn’t experience any more rectal bleeding until 4 years after she first sought treatment. A lesson in this tragic case is to be sure to document when you tell patients to “come back to see me right away if this happens again.”
23-year-old dies when myocarditis is mistaken for bronchitis
A 23-YEAR-OLD MAN PRESENTED TO THE EMERGENCY DEPARTMENT (ED) with chest tightness, cough, and fever. After a chest x-ray, the ED physician diagnosed bronchitis and sent the patient home with prescriptions for hydrocodone/acetaminophen and antibiotics. He was found dead in his bed less than 24 hours later. An autopsy determined the cause of death was myocarditis.
PLAINTIFF’S CLAIM The physician didn’t perform an electrocardiogram (EKG), which is a routine evaluation for a patient with chest pain. The EKG would have detected myocarditis.
THE DEFENSE The patient was evaluated properly. An EKG was not necessary.
VERDICT $2.9 million Massachusetts verdict.
COMMENT I think the jury got this one wrong. I don’t think an EKG is necessary for every case of acute bronchitis. However, I do wonder if the chest x-ray showed a large heart shadow.
Uterine rupture, child stillborn: $3.8M net award
Uterine rupture, child stillborn: $3.8M net award
At 35 weeks' gestation, a woman went to the emergency department (ED) with abdominal pain, fast heartbeat, and irregular contractions. Her history included three cesarean deliveries, including one with a vertical incision. She was admitted, and a cesarean delivery was planned for the next day. After 8 hours, during which the patient’s condition worsened, an emergency cesarean delivery was undertaken. A full rupture of the uterus was found; the baby’s body had extruded into the mother’s abdomen. The child was stillborn.
PARENTS’ CLAIM The stillbirth could have been avoided if the nurses had communicated the mother’s worsening condition to the physicians.
DEFENDANTS’ DEFENSE After the hospital and physicians settled prior to trial, the case continued against the nurse in charge of the mother’s care and the nurse-staffing group. Negligence was denied; all protocols were followed.
VERDICT A $2.9 million Illinois verdict was returned. With a $900,000 settlement from the hospital and physicians, the net award was $3.8 million.
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Where did rare strep A infection come from?
A 36-year-old woman reported heavy vaginal bleeding to her ObGyn. She underwent endometrial ablation in her physician’s office.
The next day, the woman called the office to report abdominal pain. She was told to stop the medication she was taking, and if the pain continued to the next day, to go to an ED. The next day, the patient went to the ED and was found to be in septic shock. During emergency laparotomy, 50 mL of purulent fluid were drained and an emergency hysterectomy was performed. Three days later, the patient died from pulmonary arrest caused by toxic shock syndrome. An autopsy revealed that the patient’s sepsis was caused by group A streptococci (GAS) infection.
ESTATE’S CLAIM The patient was not a proper candidate for endometrial ablation because of her history of chronic cervical infection. The ObGyn perforated the cervix during the procedure and tried to conceal it. At autopsy, bone wax was found in the rectal lumen that had been used to cover up damage to the cervix. The ObGyn introduced GAS bacteria into the patient’s system. The ObGyn’s staff failed to ask the proper questions when she called the day after the procedure. She should have been told to go directly to the ED.
DEFENDANTS’ DEFENSE The ObGyn did not perforate the cervix or uterus during the procedure. GAS infection is so rare that it would have been difficult to foresee or diagnose. Potentially, the patient had a chronic
cervical infection before ablation.
VERDICT A Texas defense verdict was returned.
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DURING INSERTION, IUD PERFORATES UTERINE WALL; LATER FOUND BELOW LIVER
On July 21, a 46-year-old woman went to an ObGyn for placement of an intrauterine device (IUD). Shortly after the ObGyn inserted the levonorgestrel-releasing intrauterine system (Mirena, Bayer HealthCare), the patient reported severe pelvic and abdominal pain. On July 26, the patient underwent surgical removal of the IUD.
She was discharged on July 29 but continued to report pain. She was readmitted to the hospital the next day and treated for pain. She was bed ridden for 3 weeks after IUD-removal surgery, and had a 3-month recovery before feeling pain free.
PATIENT’S CLAIM The ObGyn was negligent in perforating the patient’s uterine wall during IUD insertion, causing the device to ultimately migrate under the patient’s liver.
DEFENDANTS’ DEFENSE Uterine perforation is a known complication of IUD insertion. The IUD escaped from the patient’s uterus at a later time and not during the insertion procedure.
VERDICT A Florida verdict of $208,839 was returned; the amount was reduced to $161,058 because the medical expenses were written off by the health-care providers.
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Was travel appropriate for this pregnant woman?
A woman with a history of two premature deliveries and one miscarriage became pregnant again. She received prenatal care at an Army hospital. She traveled to Spain, where the baby was born at 31 weeks’ gestation. The baby required treatment in a neonatal intensive care unit (NICU) for 17 days. The child has cerebral palsy, with tetraplegia of all four extremities. She cannot walk without assistance and suffers severe cognitive and vision impairment.
PARENTS’ CLAIM The ObGyn at the Army hospital should not have approved the mother’s request for travel; he did so, despite knowing that the mother was at high risk for premature birth. The military medical hospital to which she was assigned in Spain could not manage a high-risk pregnancy, didn’t have a NICU, and didn’t have specialists to treat premature infants.
DEFENDANTS’ DEFENSE The ObGyn argued that he did not have access to the medical records showing the mother’s history. The patient countered that the ObGyn did indeed have the patient’s records, as he had discussed them with her.
VERDICT A $10,409,700 California verdict was returned against the ObGyn and the government facility.
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Triple-negative BrCa not diagnosed until metastasized: $5.2M
After finding lumps in both breasts, a woman in her 30s saw a nurse practitioner (NP) at an Army hospital. A radiologist reported no mass in the right breast and multiple benign-appearing anechoic lesions in the left breast after bilateral mammography and ultrasonography (US) in July 2008. The Chief of Mammography Services recommended referral to a breast surgeon, but the patient never received the letter. It was placed in her mammography file, not in the treatment file.
In November 2008, the patient returned to the clinic. Bilateral diagnostic mammography and US were ordered, but for unknown reasons, cancelled. US of the left breast was interpreted as benign in January 2009.
After imaging in March 2010, followed by a needle biopsy of the right breast, a radiologist reported finding intermediate-grade infiltrating ductal carcinoma.
The patient sought care outside the military medical system at a large university hospital. In April 2010, stage 3 triple-negative invasive ductal carcinoma (IDC) was identified. The patient underwent chemotherapy, a double mastectomy, removal of 21 lymph nodes, and breast reconstruction. She was given a 60% chance of recurrence in 5–7 years.
PATIENT’S CLAIM It was negligent to not inform her of imaging results. Biopsy should have been performed in 2008, when the IDC was likely at stage 1; treatment would have been far less aggressive. Electronic medical records showed that the 2008 mammography and US results had been “signed off” by an NP at the clinic.
DEFENDANTS’ DEFENSE While unable to concede liability, the government agency did not contest the point.
VERDICT A $5.2 million Tennessee federal court bench verdict was returned, citing failures in communication, poor and improper record keeping and retention, failure to follow-up, and an unexplained cancellation of a medical order.
_______________
Woman dies from cervical cancer: $2.3M
In 2001, a 41-year-old woman had abnormal Pap smear results but her gynecologist did not order more testing. The patient was told to return in 3 months, but she did not return until 2007—reporting abnormal bleeding, vaginal discharge, and pain. Her Pap results were normal, however, and the gynecologist did not order further testing. In 2009, the patient was found to have advanced cervical cancer. She died 2 years later.
ESTATE’S CLAIM Further testing should have been ordered in 2001, which would have likely revealed dysplasia, which can lead to cancer. The laboratory incorrectly interpreted the 2007 Pap test; if the results had been properly reported, additional testing could have been ordered.
DEFENDANTS’ DEFENSE The laboratory and patient’s estate settled for a confidential amount before trial. The gynecologist denied negligence.
VERDICT A New Jersey jury found the gynecologist 40% at fault for his actions in 2007. The jury found the laboratory 50% at fault, and the patient 10% at fault. A gross verdict of $2.33 million was returned.
_______________
Bowel injury after cesarean delivery; mother dies of sepsis
At 40 4/7 weeks' gestation, a 37-year-old woman gave birth to a healthy child by cesarean delivery. The next day, the patient had an elevated white blood cell (WBC) count with a left shift, her abdomen was tympanic but soft, and she was passing flatus and belching. The ObGyn ordered a Fleet enema; only flatus was released. A covering ObGyn ordered an abdominal radiograph, which the radiologist reported as showing postoperative ileus and mild constipation. The patient was given a second Fleet enema the next day, resulting in watery stool. She vomited 300 mL of dark green fluid.
After a rectal tube was placed 2 days later, one hard brown stool and several brown, pasty, loose, and liquid stools were returned. She vomited several times that day, and was found to have hypoactive bowel sounds with continued tympanic quality in the upper quadrants. Laboratory testing revealed continued elevated WBC count with left shift. The next day, she had hypoactive bowel sounds with brown liquid stools. Later that morning, she was able to tolerate clear liquids. The ObGyn decided to discharge her home with instructions to continue on a clear liquid diet for 2 more days before advancing her diet.
The day after discharge, she was found unresponsive at home. She was taken to the hospital, but resuscitation attempts failed. She died. An autopsy revealed that the cause of death was sepsis.
ESTATE’S CLAIM The ObGyn was negligent in failing to diagnose and treat a postoperative intra-abdominal infection caused by bowel perforation. A surgical consult should have been obtained. The woman was prematurely discharged. The radiologist failed to report the presence of free air on the abdominal x-ray.
DEFENDANTS’ DEFENSE The case was settled during trial.
VERDICT A $1 million Maryland settlement was reached.
_______________
Right ureter injury detected and repaired
During laparoscopic-assisted vaginal hysterectomy, the ObGyn detected and repaired an injury to the right ureter. The patient’s recovery was delayed by the injury.
PATIENT’S CLAIM The ObGyn was negligent in using a Kleppinger bipolar cauterizing instrument to cauterize the vaginal cuff. Thermal overspray from the instrument or the instrument itself damaged the ureter. The ObGyn was also negligent in not performing diagnostic cystoscopy to confirm patency of the ureter after the repair was made.
PHYSICIAN’S DEFENSE Ureter injury is a known risk of the procedure. All procedures were performed according to protocol.
VERDICT A Florida defense verdict was returned.
_______________
Failure to detect inflammatory BrCa; woman dies
A 42-year-old woman underwent mammography in February 2002 after reporting pain, discoloration, inflammation, and swelling in her left breast. The radiologist who interpreted the mammography suggested a biopsy for a differential diagnosis of mastitis or inflammatory carcinoma. The biopsy results were negative.
The patient’s symptoms persisted, and she underwent US in late May 2002. Another radiologist interpreted the US, noting that the patient could not tolerate compression, which led to less than optimal evaluation. The radiologist suggested that mastitis was the likely cause of the patient’s symptoms.
The patient then consulted a surgeon, who ordered mammography and magnetic resonance imaging (MRI) followed by biopsy, which indicated cancer. The patient underwent a mastectomy but metastasis had already occurred. She died at age 50 prior to the trial.
ESTATE’S CLAIM If the cancer had been diagnosed earlier, the outcome would have been better. Both radiologists misinterpreted the mammographies.
DEFENDANTS’ DEFENSE The mammographies had been properly interpreted. Any missed diagnosis would not have impacted the outcome due to the type of cancer. The scans had been released to the patient, but were subsequently lost; an adverse interference instruction was given to the jury.
VERDICT A New York defense verdict was returned.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Uterine rupture, child stillborn: $3.8M net award
At 35 weeks' gestation, a woman went to the emergency department (ED) with abdominal pain, fast heartbeat, and irregular contractions. Her history included three cesarean deliveries, including one with a vertical incision. She was admitted, and a cesarean delivery was planned for the next day. After 8 hours, during which the patient’s condition worsened, an emergency cesarean delivery was undertaken. A full rupture of the uterus was found; the baby’s body had extruded into the mother’s abdomen. The child was stillborn.
PARENTS’ CLAIM The stillbirth could have been avoided if the nurses had communicated the mother’s worsening condition to the physicians.
DEFENDANTS’ DEFENSE After the hospital and physicians settled prior to trial, the case continued against the nurse in charge of the mother’s care and the nurse-staffing group. Negligence was denied; all protocols were followed.
VERDICT A $2.9 million Illinois verdict was returned. With a $900,000 settlement from the hospital and physicians, the net award was $3.8 million.
_______________
Where did rare strep A infection come from?
A 36-year-old woman reported heavy vaginal bleeding to her ObGyn. She underwent endometrial ablation in her physician’s office.
The next day, the woman called the office to report abdominal pain. She was told to stop the medication she was taking, and if the pain continued to the next day, to go to an ED. The next day, the patient went to the ED and was found to be in septic shock. During emergency laparotomy, 50 mL of purulent fluid were drained and an emergency hysterectomy was performed. Three days later, the patient died from pulmonary arrest caused by toxic shock syndrome. An autopsy revealed that the patient’s sepsis was caused by group A streptococci (GAS) infection.
ESTATE’S CLAIM The patient was not a proper candidate for endometrial ablation because of her history of chronic cervical infection. The ObGyn perforated the cervix during the procedure and tried to conceal it. At autopsy, bone wax was found in the rectal lumen that had been used to cover up damage to the cervix. The ObGyn introduced GAS bacteria into the patient’s system. The ObGyn’s staff failed to ask the proper questions when she called the day after the procedure. She should have been told to go directly to the ED.
DEFENDANTS’ DEFENSE The ObGyn did not perforate the cervix or uterus during the procedure. GAS infection is so rare that it would have been difficult to foresee or diagnose. Potentially, the patient had a chronic
cervical infection before ablation.
VERDICT A Texas defense verdict was returned.
_______________
DURING INSERTION, IUD PERFORATES UTERINE WALL; LATER FOUND BELOW LIVER
On July 21, a 46-year-old woman went to an ObGyn for placement of an intrauterine device (IUD). Shortly after the ObGyn inserted the levonorgestrel-releasing intrauterine system (Mirena, Bayer HealthCare), the patient reported severe pelvic and abdominal pain. On July 26, the patient underwent surgical removal of the IUD.
She was discharged on July 29 but continued to report pain. She was readmitted to the hospital the next day and treated for pain. She was bed ridden for 3 weeks after IUD-removal surgery, and had a 3-month recovery before feeling pain free.
PATIENT’S CLAIM The ObGyn was negligent in perforating the patient’s uterine wall during IUD insertion, causing the device to ultimately migrate under the patient’s liver.
DEFENDANTS’ DEFENSE Uterine perforation is a known complication of IUD insertion. The IUD escaped from the patient’s uterus at a later time and not during the insertion procedure.
VERDICT A Florida verdict of $208,839 was returned; the amount was reduced to $161,058 because the medical expenses were written off by the health-care providers.
_______________
Was travel appropriate for this pregnant woman?
A woman with a history of two premature deliveries and one miscarriage became pregnant again. She received prenatal care at an Army hospital. She traveled to Spain, where the baby was born at 31 weeks’ gestation. The baby required treatment in a neonatal intensive care unit (NICU) for 17 days. The child has cerebral palsy, with tetraplegia of all four extremities. She cannot walk without assistance and suffers severe cognitive and vision impairment.
PARENTS’ CLAIM The ObGyn at the Army hospital should not have approved the mother’s request for travel; he did so, despite knowing that the mother was at high risk for premature birth. The military medical hospital to which she was assigned in Spain could not manage a high-risk pregnancy, didn’t have a NICU, and didn’t have specialists to treat premature infants.
DEFENDANTS’ DEFENSE The ObGyn argued that he did not have access to the medical records showing the mother’s history. The patient countered that the ObGyn did indeed have the patient’s records, as he had discussed them with her.
VERDICT A $10,409,700 California verdict was returned against the ObGyn and the government facility.
_______________
Triple-negative BrCa not diagnosed until metastasized: $5.2M
After finding lumps in both breasts, a woman in her 30s saw a nurse practitioner (NP) at an Army hospital. A radiologist reported no mass in the right breast and multiple benign-appearing anechoic lesions in the left breast after bilateral mammography and ultrasonography (US) in July 2008. The Chief of Mammography Services recommended referral to a breast surgeon, but the patient never received the letter. It was placed in her mammography file, not in the treatment file.
In November 2008, the patient returned to the clinic. Bilateral diagnostic mammography and US were ordered, but for unknown reasons, cancelled. US of the left breast was interpreted as benign in January 2009.
After imaging in March 2010, followed by a needle biopsy of the right breast, a radiologist reported finding intermediate-grade infiltrating ductal carcinoma.
The patient sought care outside the military medical system at a large university hospital. In April 2010, stage 3 triple-negative invasive ductal carcinoma (IDC) was identified. The patient underwent chemotherapy, a double mastectomy, removal of 21 lymph nodes, and breast reconstruction. She was given a 60% chance of recurrence in 5–7 years.
PATIENT’S CLAIM It was negligent to not inform her of imaging results. Biopsy should have been performed in 2008, when the IDC was likely at stage 1; treatment would have been far less aggressive. Electronic medical records showed that the 2008 mammography and US results had been “signed off” by an NP at the clinic.
DEFENDANTS’ DEFENSE While unable to concede liability, the government agency did not contest the point.
VERDICT A $5.2 million Tennessee federal court bench verdict was returned, citing failures in communication, poor and improper record keeping and retention, failure to follow-up, and an unexplained cancellation of a medical order.
_______________
Woman dies from cervical cancer: $2.3M
In 2001, a 41-year-old woman had abnormal Pap smear results but her gynecologist did not order more testing. The patient was told to return in 3 months, but she did not return until 2007—reporting abnormal bleeding, vaginal discharge, and pain. Her Pap results were normal, however, and the gynecologist did not order further testing. In 2009, the patient was found to have advanced cervical cancer. She died 2 years later.
ESTATE’S CLAIM Further testing should have been ordered in 2001, which would have likely revealed dysplasia, which can lead to cancer. The laboratory incorrectly interpreted the 2007 Pap test; if the results had been properly reported, additional testing could have been ordered.
DEFENDANTS’ DEFENSE The laboratory and patient’s estate settled for a confidential amount before trial. The gynecologist denied negligence.
VERDICT A New Jersey jury found the gynecologist 40% at fault for his actions in 2007. The jury found the laboratory 50% at fault, and the patient 10% at fault. A gross verdict of $2.33 million was returned.
_______________
Bowel injury after cesarean delivery; mother dies of sepsis
At 40 4/7 weeks' gestation, a 37-year-old woman gave birth to a healthy child by cesarean delivery. The next day, the patient had an elevated white blood cell (WBC) count with a left shift, her abdomen was tympanic but soft, and she was passing flatus and belching. The ObGyn ordered a Fleet enema; only flatus was released. A covering ObGyn ordered an abdominal radiograph, which the radiologist reported as showing postoperative ileus and mild constipation. The patient was given a second Fleet enema the next day, resulting in watery stool. She vomited 300 mL of dark green fluid.
After a rectal tube was placed 2 days later, one hard brown stool and several brown, pasty, loose, and liquid stools were returned. She vomited several times that day, and was found to have hypoactive bowel sounds with continued tympanic quality in the upper quadrants. Laboratory testing revealed continued elevated WBC count with left shift. The next day, she had hypoactive bowel sounds with brown liquid stools. Later that morning, she was able to tolerate clear liquids. The ObGyn decided to discharge her home with instructions to continue on a clear liquid diet for 2 more days before advancing her diet.
The day after discharge, she was found unresponsive at home. She was taken to the hospital, but resuscitation attempts failed. She died. An autopsy revealed that the cause of death was sepsis.
ESTATE’S CLAIM The ObGyn was negligent in failing to diagnose and treat a postoperative intra-abdominal infection caused by bowel perforation. A surgical consult should have been obtained. The woman was prematurely discharged. The radiologist failed to report the presence of free air on the abdominal x-ray.
DEFENDANTS’ DEFENSE The case was settled during trial.
VERDICT A $1 million Maryland settlement was reached.
_______________
Right ureter injury detected and repaired
During laparoscopic-assisted vaginal hysterectomy, the ObGyn detected and repaired an injury to the right ureter. The patient’s recovery was delayed by the injury.
PATIENT’S CLAIM The ObGyn was negligent in using a Kleppinger bipolar cauterizing instrument to cauterize the vaginal cuff. Thermal overspray from the instrument or the instrument itself damaged the ureter. The ObGyn was also negligent in not performing diagnostic cystoscopy to confirm patency of the ureter after the repair was made.
PHYSICIAN’S DEFENSE Ureter injury is a known risk of the procedure. All procedures were performed according to protocol.
VERDICT A Florida defense verdict was returned.
_______________
Failure to detect inflammatory BrCa; woman dies
A 42-year-old woman underwent mammography in February 2002 after reporting pain, discoloration, inflammation, and swelling in her left breast. The radiologist who interpreted the mammography suggested a biopsy for a differential diagnosis of mastitis or inflammatory carcinoma. The biopsy results were negative.
The patient’s symptoms persisted, and she underwent US in late May 2002. Another radiologist interpreted the US, noting that the patient could not tolerate compression, which led to less than optimal evaluation. The radiologist suggested that mastitis was the likely cause of the patient’s symptoms.
The patient then consulted a surgeon, who ordered mammography and magnetic resonance imaging (MRI) followed by biopsy, which indicated cancer. The patient underwent a mastectomy but metastasis had already occurred. She died at age 50 prior to the trial.
ESTATE’S CLAIM If the cancer had been diagnosed earlier, the outcome would have been better. Both radiologists misinterpreted the mammographies.
DEFENDANTS’ DEFENSE The mammographies had been properly interpreted. Any missed diagnosis would not have impacted the outcome due to the type of cancer. The scans had been released to the patient, but were subsequently lost; an adverse interference instruction was given to the jury.
VERDICT A New York defense verdict was returned.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Uterine rupture, child stillborn: $3.8M net award
At 35 weeks' gestation, a woman went to the emergency department (ED) with abdominal pain, fast heartbeat, and irregular contractions. Her history included three cesarean deliveries, including one with a vertical incision. She was admitted, and a cesarean delivery was planned for the next day. After 8 hours, during which the patient’s condition worsened, an emergency cesarean delivery was undertaken. A full rupture of the uterus was found; the baby’s body had extruded into the mother’s abdomen. The child was stillborn.
PARENTS’ CLAIM The stillbirth could have been avoided if the nurses had communicated the mother’s worsening condition to the physicians.
DEFENDANTS’ DEFENSE After the hospital and physicians settled prior to trial, the case continued against the nurse in charge of the mother’s care and the nurse-staffing group. Negligence was denied; all protocols were followed.
VERDICT A $2.9 million Illinois verdict was returned. With a $900,000 settlement from the hospital and physicians, the net award was $3.8 million.
_______________
Where did rare strep A infection come from?
A 36-year-old woman reported heavy vaginal bleeding to her ObGyn. She underwent endometrial ablation in her physician’s office.
The next day, the woman called the office to report abdominal pain. She was told to stop the medication she was taking, and if the pain continued to the next day, to go to an ED. The next day, the patient went to the ED and was found to be in septic shock. During emergency laparotomy, 50 mL of purulent fluid were drained and an emergency hysterectomy was performed. Three days later, the patient died from pulmonary arrest caused by toxic shock syndrome. An autopsy revealed that the patient’s sepsis was caused by group A streptococci (GAS) infection.
ESTATE’S CLAIM The patient was not a proper candidate for endometrial ablation because of her history of chronic cervical infection. The ObGyn perforated the cervix during the procedure and tried to conceal it. At autopsy, bone wax was found in the rectal lumen that had been used to cover up damage to the cervix. The ObGyn introduced GAS bacteria into the patient’s system. The ObGyn’s staff failed to ask the proper questions when she called the day after the procedure. She should have been told to go directly to the ED.
DEFENDANTS’ DEFENSE The ObGyn did not perforate the cervix or uterus during the procedure. GAS infection is so rare that it would have been difficult to foresee or diagnose. Potentially, the patient had a chronic
cervical infection before ablation.
VERDICT A Texas defense verdict was returned.
_______________
DURING INSERTION, IUD PERFORATES UTERINE WALL; LATER FOUND BELOW LIVER
On July 21, a 46-year-old woman went to an ObGyn for placement of an intrauterine device (IUD). Shortly after the ObGyn inserted the levonorgestrel-releasing intrauterine system (Mirena, Bayer HealthCare), the patient reported severe pelvic and abdominal pain. On July 26, the patient underwent surgical removal of the IUD.
She was discharged on July 29 but continued to report pain. She was readmitted to the hospital the next day and treated for pain. She was bed ridden for 3 weeks after IUD-removal surgery, and had a 3-month recovery before feeling pain free.
PATIENT’S CLAIM The ObGyn was negligent in perforating the patient’s uterine wall during IUD insertion, causing the device to ultimately migrate under the patient’s liver.
DEFENDANTS’ DEFENSE Uterine perforation is a known complication of IUD insertion. The IUD escaped from the patient’s uterus at a later time and not during the insertion procedure.
VERDICT A Florida verdict of $208,839 was returned; the amount was reduced to $161,058 because the medical expenses were written off by the health-care providers.
_______________
Was travel appropriate for this pregnant woman?
A woman with a history of two premature deliveries and one miscarriage became pregnant again. She received prenatal care at an Army hospital. She traveled to Spain, where the baby was born at 31 weeks’ gestation. The baby required treatment in a neonatal intensive care unit (NICU) for 17 days. The child has cerebral palsy, with tetraplegia of all four extremities. She cannot walk without assistance and suffers severe cognitive and vision impairment.
PARENTS’ CLAIM The ObGyn at the Army hospital should not have approved the mother’s request for travel; he did so, despite knowing that the mother was at high risk for premature birth. The military medical hospital to which she was assigned in Spain could not manage a high-risk pregnancy, didn’t have a NICU, and didn’t have specialists to treat premature infants.
DEFENDANTS’ DEFENSE The ObGyn argued that he did not have access to the medical records showing the mother’s history. The patient countered that the ObGyn did indeed have the patient’s records, as he had discussed them with her.
VERDICT A $10,409,700 California verdict was returned against the ObGyn and the government facility.
_______________
Triple-negative BrCa not diagnosed until metastasized: $5.2M
After finding lumps in both breasts, a woman in her 30s saw a nurse practitioner (NP) at an Army hospital. A radiologist reported no mass in the right breast and multiple benign-appearing anechoic lesions in the left breast after bilateral mammography and ultrasonography (US) in July 2008. The Chief of Mammography Services recommended referral to a breast surgeon, but the patient never received the letter. It was placed in her mammography file, not in the treatment file.
In November 2008, the patient returned to the clinic. Bilateral diagnostic mammography and US were ordered, but for unknown reasons, cancelled. US of the left breast was interpreted as benign in January 2009.
After imaging in March 2010, followed by a needle biopsy of the right breast, a radiologist reported finding intermediate-grade infiltrating ductal carcinoma.
The patient sought care outside the military medical system at a large university hospital. In April 2010, stage 3 triple-negative invasive ductal carcinoma (IDC) was identified. The patient underwent chemotherapy, a double mastectomy, removal of 21 lymph nodes, and breast reconstruction. She was given a 60% chance of recurrence in 5–7 years.
PATIENT’S CLAIM It was negligent to not inform her of imaging results. Biopsy should have been performed in 2008, when the IDC was likely at stage 1; treatment would have been far less aggressive. Electronic medical records showed that the 2008 mammography and US results had been “signed off” by an NP at the clinic.
DEFENDANTS’ DEFENSE While unable to concede liability, the government agency did not contest the point.
VERDICT A $5.2 million Tennessee federal court bench verdict was returned, citing failures in communication, poor and improper record keeping and retention, failure to follow-up, and an unexplained cancellation of a medical order.
_______________
Woman dies from cervical cancer: $2.3M
In 2001, a 41-year-old woman had abnormal Pap smear results but her gynecologist did not order more testing. The patient was told to return in 3 months, but she did not return until 2007—reporting abnormal bleeding, vaginal discharge, and pain. Her Pap results were normal, however, and the gynecologist did not order further testing. In 2009, the patient was found to have advanced cervical cancer. She died 2 years later.
ESTATE’S CLAIM Further testing should have been ordered in 2001, which would have likely revealed dysplasia, which can lead to cancer. The laboratory incorrectly interpreted the 2007 Pap test; if the results had been properly reported, additional testing could have been ordered.
DEFENDANTS’ DEFENSE The laboratory and patient’s estate settled for a confidential amount before trial. The gynecologist denied negligence.
VERDICT A New Jersey jury found the gynecologist 40% at fault for his actions in 2007. The jury found the laboratory 50% at fault, and the patient 10% at fault. A gross verdict of $2.33 million was returned.
_______________
Bowel injury after cesarean delivery; mother dies of sepsis
At 40 4/7 weeks' gestation, a 37-year-old woman gave birth to a healthy child by cesarean delivery. The next day, the patient had an elevated white blood cell (WBC) count with a left shift, her abdomen was tympanic but soft, and she was passing flatus and belching. The ObGyn ordered a Fleet enema; only flatus was released. A covering ObGyn ordered an abdominal radiograph, which the radiologist reported as showing postoperative ileus and mild constipation. The patient was given a second Fleet enema the next day, resulting in watery stool. She vomited 300 mL of dark green fluid.
After a rectal tube was placed 2 days later, one hard brown stool and several brown, pasty, loose, and liquid stools were returned. She vomited several times that day, and was found to have hypoactive bowel sounds with continued tympanic quality in the upper quadrants. Laboratory testing revealed continued elevated WBC count with left shift. The next day, she had hypoactive bowel sounds with brown liquid stools. Later that morning, she was able to tolerate clear liquids. The ObGyn decided to discharge her home with instructions to continue on a clear liquid diet for 2 more days before advancing her diet.
The day after discharge, she was found unresponsive at home. She was taken to the hospital, but resuscitation attempts failed. She died. An autopsy revealed that the cause of death was sepsis.
ESTATE’S CLAIM The ObGyn was negligent in failing to diagnose and treat a postoperative intra-abdominal infection caused by bowel perforation. A surgical consult should have been obtained. The woman was prematurely discharged. The radiologist failed to report the presence of free air on the abdominal x-ray.
DEFENDANTS’ DEFENSE The case was settled during trial.
VERDICT A $1 million Maryland settlement was reached.
_______________
Right ureter injury detected and repaired
During laparoscopic-assisted vaginal hysterectomy, the ObGyn detected and repaired an injury to the right ureter. The patient’s recovery was delayed by the injury.
PATIENT’S CLAIM The ObGyn was negligent in using a Kleppinger bipolar cauterizing instrument to cauterize the vaginal cuff. Thermal overspray from the instrument or the instrument itself damaged the ureter. The ObGyn was also negligent in not performing diagnostic cystoscopy to confirm patency of the ureter after the repair was made.
PHYSICIAN’S DEFENSE Ureter injury is a known risk of the procedure. All procedures were performed according to protocol.
VERDICT A Florida defense verdict was returned.
_______________
Failure to detect inflammatory BrCa; woman dies
A 42-year-old woman underwent mammography in February 2002 after reporting pain, discoloration, inflammation, and swelling in her left breast. The radiologist who interpreted the mammography suggested a biopsy for a differential diagnosis of mastitis or inflammatory carcinoma. The biopsy results were negative.
The patient’s symptoms persisted, and she underwent US in late May 2002. Another radiologist interpreted the US, noting that the patient could not tolerate compression, which led to less than optimal evaluation. The radiologist suggested that mastitis was the likely cause of the patient’s symptoms.
The patient then consulted a surgeon, who ordered mammography and magnetic resonance imaging (MRI) followed by biopsy, which indicated cancer. The patient underwent a mastectomy but metastasis had already occurred. She died at age 50 prior to the trial.
ESTATE’S CLAIM If the cancer had been diagnosed earlier, the outcome would have been better. Both radiologists misinterpreted the mammographies.
DEFENDANTS’ DEFENSE The mammographies had been properly interpreted. Any missed diagnosis would not have impacted the outcome due to the type of cancer. The scans had been released to the patient, but were subsequently lost; an adverse interference instruction was given to the jury.
VERDICT A New York defense verdict was returned.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
More inclusions:
- Where did rare strep A infection come from?
- During insertion, IUD perforates uterine wall; Later found below liver
- Was travel appropriate for this pregnant woman?
- Triple-negative BrCa not diagnosed until metastasized: $5.2M
- Woman dies from cervical cancer: $2.3M
- Bowel injury after cesarean delivery; mother dies of sepsis
- Right ureter injury detected and repaired
- Failure to detect inflammatory BrCa; woman dies
Was fetus’ wrist injured during cesarean delivery?
Was fetus’ wrist injured during cesarean delivery?
At 34 weeks’ gestation, a 39-year-old woman went to the hospital in preterm labor. Her history included a prior cesarean delivery. Ultrasonography (US) showed that the fetus was in a double-footling breech position. The ObGyn decided to perform a cesarean delivery when the fetal heart-rate monitor indicated distress.
After making a midline incision through the earlier scar, the ObGyn created a low transverse uterine incision with a scalpel. The mother’s uterus was thick because labor had not progressed. When the ObGyn was unable to deliver the baby through the low transverse incision, she performed a T-extension of the incision using bandage scissors while placing her free hand inside the uterus to shield the fetus from injury. After extensive manipulation, the baby was delivered and immediately handed to a neonatologist. After surgery, the neonatologist told the mother that the baby had sustained two lacerations to the ulnar side of the right wrist. The newborn was airlifted to another hospital for treatment of sepsis. There, an orthopedic hand surgeon examined the child and determined that the lacerations were superficial and only required sutures. The orthopedist saw the infant a month later and believed there was no significant wrist injury.
When the child began preschool, she started to experience cold intolerance and difficulty writing with her right hand. The child was referred to a pediatric neurologist, who found no nerve damage and ordered occupational therapy.
The original orthopedic surgeon examined the child when she was 7 years old and determined that the flexor carpi ulnaris tendon had been completely severed with a partial injury to the ulnar nerve. He recommended a return visit at age 14 for full assessment of the wrist injury.
PARENTS’ CLAIM The ObGyn did not properly shield the fetus when performing the T-extension incision during cesarean delivery. The child’s weakness will increase with age, ruling out some occupations.
PHYSICIAN’S DEFENSE The ObGyn was not negligent; she had provided adequate protection of the fetus during both incisions.
VERDICT An Illinois defense verdict was returned.
Woman dies after tubal ligation
After a 42-year-old woman underwent tubal ligation, her surgeon was concerned about a possible bowel perforation and admitted her to the hospital. The next morning, a computed tomography (CT) scan of the abdomen did not reveal bowel injury.
That afternoon, when the patient reported shortness of breath, the surgeon called the hospitalist with concern for pulmonary embolism (PE). The hospitalist immediately ordered a CT scan of the chest, initiated PE protocol, and wrote “r/o PE” on the chart. A radiologist reminded the hospitalist of the earlier CT scan with concern for kidney damage from another dye study. The hospitalist cancelled the CT scan and PE protocol. After waiting 17 hours to run any further tests, a CT scan revealed massive bilateral PE. The patient was transferred to the ICU, but died the next day.
PATIENT’S CLAIM The 17-hour delay was negligent.
PHYSICIAN’S DEFENSE There was no negligence. The patient died of septic shock, not PE.
VERDICT A $4 million Virginia verdict was returned.
Child born without hand and forearm
During prenatal care, a mother underwent US at 20 and 36 weeks; both studies were reported as normal. The child was born missing his left hand and part of his left forearm due to a congenital amputation. The child will require prosthetics for life.
PATIENT’S CLAIM The condition should have been seen during prenatal US; an abortion was still an option at 20 weeks.
DEFENDANTS’ DEFENSE US was properly performed and evaluated. It can be difficult to differentiate the right from left extremities.
VERDICT A California defense verdict was returned.
After starting Yasmin, woman has stroke with permanent paralysis: $16.5M total award
When a 37-year-old woman reported irregular menstruation, her ObGyn prescribed drospirenone/ethinyl estradiol (Yasmin; Bayer). Thirteen days after starting the drug, the patient had a stroke. She is paralyzed on her left side, has limited ability to speak, cannot use her left arm and leg, and requires 24-hour care.
PATIENT’S CLAIM The ObGyn should have recognized that Yasmin was not appropriate for this patient because of the drug’s clotting risks. The patient’s risk factors included her age (over 35), borderline hypertension, overweight, history of smoking, and high cholesterol. The ObGyn should have offered safer alternatives, such as a progesterone-only pill. The US Food and Drug Administration (FDA) issued a safety warning that all drospirenone-containing drugs may be associated with a higher risk of venous thrombosis during the first 6 months of use.
DEFENDANTS’ DEFENSE According to Bayer, Yasmin is safe, and remains on the market. It was an appropriate drug to treat her irregular bleeding.
VERDICT Claims against the medical center that referred the patient to the ObGyn were settled for $2.5 million before trial. A $14 million Illinois verdict was returned against the ObGyn, for a total award of $16.5 million.
Who is at fault when pelvic mesh erodes?
In January 2011, an ObGyn implanted the Gynecare TVT Obturator System (TVT‑O; Ethicon) during a midurethral sling procedure to treat stress urinary incontinence (SUI) in a woman in her 60s. Shortly thereafter, the ObGyn left practice because of early-onset Alzheimer’s disease, and the patient’s care was taken over by a gynecologist.
At the 2-month postoperative visit, the gynecologist found that the mesh had eroded into the patient’s vagina. The gynecologist simply cut the mesh with a scissor, charted that a small erosion was present, and prescribed estrogen cream.
The patient continued to report pain, discomfort, pressure, difficulty voiding urine, continued incontinence, vaginal discharge, scarring, infection, odor, and bleeding.
PATIENT’S CLAIM The polypropylene mesh used during the midurethral sling procedure has been shown to be incompatible with human tissue. It promotes an immune response, which stimulates degradation of the pelvic tissue and can contribute to the development of severe adverse reactions to the mesh. Ethicon negligently designed, manufactured, marketed, labeled, and packaged the pelvic mesh products.
DEFENDANTS’ DEFENSE Proper warnings were provided about the health risks associated with polypropylene mesh products. The medical device was not properly sized.
VERDICT A Texas jury rejected the patient’s claims that Ethicon did not provide proper warnings about the sling’s health risks and declined to award punitive damages.
However, the jury decided that the mesh implant was defectively designed, and returned a $1.2 million verdict against Ethicon.
Was suspected bowel injury treated properly?
A 40-year-old woman was referred to an ObGyn after reporting abnormal uterine bleeding to her primary care physician. The patient had very light menses every few weeks. The ObGyn performed an ablation procedure, without relief. A month later, the ObGyn performed robot-assisted laparoscopic hysterectomy. The next day, the patient reported abdominal pain. Suspecting a bowel injury, the ObGyn ordered a CT scan; the bowel appeared normal, so the ObGyn referred the patient to a surgeon. During exploratory laparotomy, the surgeon found and repaired a bowel injury. The patient developed significant complications from a necrotizing infection that included respiratory distress and ongoing wound care.
PATIENT’S CLAIM Conservative treatment should have been offered before surgery. The ObGyn should have waited longer after the ablation procedure before doing the hysterectomy. The ObGyn should have checked for a possible bowel injury before closing the hysterectomy.
PHYSICIAN’S DEFENSE The bowel injury is a known complication of the procedure and was recognized and repaired in a timely manner.
VERDICT A Kentucky defense verdict was returned.
Pap smear improperly interpreted: Woman dies from cervical cancer
A 37-year-old woman underwent a pap smear in 2008 that was read by a cytotechnologist as normal. Two years later, the patient was found to have a golf-ball–sized cancerous tumor. She died from cervical cancer in 2011.
ESTATE’S CLAIM The cytotechnologist was negligent in misreading the 2008 Pap smear. If treatment had been started in 2008, the cancer could have been resolved with a simple conization biopsy.
DEFENDANTS’ DEFENSE The Pap smear interpretation was reasonable. The cancer could not have been diagnosed in 2008. The patient was at fault for failing to follow-up Pap smears during the next 2 years.
VERDICT After assigning 75% fault to the cytotechnologist and 25% fault to the patient, a Florida jury returned a $20,870,200 verdict, which was reduced to $15,816,699.
Disastrous off-label use of anticoagulation
When a pelvic abscess was found, a 50-year-old woman was admitted to the hospital for treatment. She was taking warfarin due to a history of venous thromboembolism.
Before the procedure, her physicians attempted to temporarily reverse her anticoagulation by administering Factor IX Complex (Profilnine SD, Grifols Biologicals). The dose ordered for the patient was nearly double the maximum recommended weight-based dose. Almost immediately after receiving the infusion, the patient went into cardiopulmonary arrest and died. An autopsy found the cause of death to be pulmonary emboli (PE).
ESTATE’S CLAIM An excessive dose of Profilnine caused PE. At the time of the incident, Profilnine was not FDA approved for warfarin reversal, although some off-label uses were recognized in emergent situations, such as intracranial bleeds.
DEFENDANTS’ DEFENSE The case was settled during the trial.
VERDICT A $1.25 million Virginia settlement was reached.
Vesicovaginal fistula from ureteral injury
At a women’s health clinic, a patient reported continuous, heavy vaginal bleeding; pain; and shortness of breath when walking. She had a history of endometritis and multiple abdominal surgeries. Examination disclosed a profuse vaginal discharge, a normal cervix, and an enlarged uterus. The patient consented to abdominal hysterectomy and bilateral salpingo-oophorectomy performed by an ObGyn assisted by a resident.
During surgery, the ObGyn found that the patient’s uterus was at 16 to 20 weeks’ gestation size, with multiple serosal uterine fibroids and frank pus and necrosed fibroid tumors within the uterine cavity. The procedure took longer than planned because of extensive adhesions. After surgery, the patient was anemic and was given a beta-blocker for tachycardia. She was discharged 3 days later with 48 hours’ worth of intravenous antibiotics.
A month later, the patient reported urinary incontinence. She saw a urologist, who found a vesicovaginal fistula. The patient underwent nephrostomy-tube placement. Right ureterolysis and a right ureteral reimplant was performed 4 months later.
PATIENT’S CLAIM The ObGyn injured the right ureter during surgery.
DEFENDANTS’ DEFENSE The ureter injury is a known risk of the procedure. The injury was due to an infection or delayed effects of ischemia. The patient had a good recovery with no residual injury.
VERDICT A Michigan defense verdict was returned.
Why did mother die after delivering twins?
After a 35-year-old woman gave birth to twins by cesarean delivery, she died. At autopsy, 4 liters of blood were found in her abdomen.
ESTATE’S CLAIM The ObGyn failed to recognize and treat an arterial or venous bleed during surgery.
DEFENDANTS’ DEFENSE The patient died from amniotic fluid embolism. Autopsy results showed right ventricular heart failure, respiratory failure, and disseminated intravascular coagulation.
VERDICT A Florida defense verdict was returned.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Was fetus’ wrist injured during cesarean delivery?
At 34 weeks’ gestation, a 39-year-old woman went to the hospital in preterm labor. Her history included a prior cesarean delivery. Ultrasonography (US) showed that the fetus was in a double-footling breech position. The ObGyn decided to perform a cesarean delivery when the fetal heart-rate monitor indicated distress.
After making a midline incision through the earlier scar, the ObGyn created a low transverse uterine incision with a scalpel. The mother’s uterus was thick because labor had not progressed. When the ObGyn was unable to deliver the baby through the low transverse incision, she performed a T-extension of the incision using bandage scissors while placing her free hand inside the uterus to shield the fetus from injury. After extensive manipulation, the baby was delivered and immediately handed to a neonatologist. After surgery, the neonatologist told the mother that the baby had sustained two lacerations to the ulnar side of the right wrist. The newborn was airlifted to another hospital for treatment of sepsis. There, an orthopedic hand surgeon examined the child and determined that the lacerations were superficial and only required sutures. The orthopedist saw the infant a month later and believed there was no significant wrist injury.
When the child began preschool, she started to experience cold intolerance and difficulty writing with her right hand. The child was referred to a pediatric neurologist, who found no nerve damage and ordered occupational therapy.
The original orthopedic surgeon examined the child when she was 7 years old and determined that the flexor carpi ulnaris tendon had been completely severed with a partial injury to the ulnar nerve. He recommended a return visit at age 14 for full assessment of the wrist injury.
PARENTS’ CLAIM The ObGyn did not properly shield the fetus when performing the T-extension incision during cesarean delivery. The child’s weakness will increase with age, ruling out some occupations.
PHYSICIAN’S DEFENSE The ObGyn was not negligent; she had provided adequate protection of the fetus during both incisions.
VERDICT An Illinois defense verdict was returned.
Woman dies after tubal ligation
After a 42-year-old woman underwent tubal ligation, her surgeon was concerned about a possible bowel perforation and admitted her to the hospital. The next morning, a computed tomography (CT) scan of the abdomen did not reveal bowel injury.
That afternoon, when the patient reported shortness of breath, the surgeon called the hospitalist with concern for pulmonary embolism (PE). The hospitalist immediately ordered a CT scan of the chest, initiated PE protocol, and wrote “r/o PE” on the chart. A radiologist reminded the hospitalist of the earlier CT scan with concern for kidney damage from another dye study. The hospitalist cancelled the CT scan and PE protocol. After waiting 17 hours to run any further tests, a CT scan revealed massive bilateral PE. The patient was transferred to the ICU, but died the next day.
PATIENT’S CLAIM The 17-hour delay was negligent.
PHYSICIAN’S DEFENSE There was no negligence. The patient died of septic shock, not PE.
VERDICT A $4 million Virginia verdict was returned.
Child born without hand and forearm
During prenatal care, a mother underwent US at 20 and 36 weeks; both studies were reported as normal. The child was born missing his left hand and part of his left forearm due to a congenital amputation. The child will require prosthetics for life.
PATIENT’S CLAIM The condition should have been seen during prenatal US; an abortion was still an option at 20 weeks.
DEFENDANTS’ DEFENSE US was properly performed and evaluated. It can be difficult to differentiate the right from left extremities.
VERDICT A California defense verdict was returned.
After starting Yasmin, woman has stroke with permanent paralysis: $16.5M total award
When a 37-year-old woman reported irregular menstruation, her ObGyn prescribed drospirenone/ethinyl estradiol (Yasmin; Bayer). Thirteen days after starting the drug, the patient had a stroke. She is paralyzed on her left side, has limited ability to speak, cannot use her left arm and leg, and requires 24-hour care.
PATIENT’S CLAIM The ObGyn should have recognized that Yasmin was not appropriate for this patient because of the drug’s clotting risks. The patient’s risk factors included her age (over 35), borderline hypertension, overweight, history of smoking, and high cholesterol. The ObGyn should have offered safer alternatives, such as a progesterone-only pill. The US Food and Drug Administration (FDA) issued a safety warning that all drospirenone-containing drugs may be associated with a higher risk of venous thrombosis during the first 6 months of use.
DEFENDANTS’ DEFENSE According to Bayer, Yasmin is safe, and remains on the market. It was an appropriate drug to treat her irregular bleeding.
VERDICT Claims against the medical center that referred the patient to the ObGyn were settled for $2.5 million before trial. A $14 million Illinois verdict was returned against the ObGyn, for a total award of $16.5 million.
Who is at fault when pelvic mesh erodes?
In January 2011, an ObGyn implanted the Gynecare TVT Obturator System (TVT‑O; Ethicon) during a midurethral sling procedure to treat stress urinary incontinence (SUI) in a woman in her 60s. Shortly thereafter, the ObGyn left practice because of early-onset Alzheimer’s disease, and the patient’s care was taken over by a gynecologist.
At the 2-month postoperative visit, the gynecologist found that the mesh had eroded into the patient’s vagina. The gynecologist simply cut the mesh with a scissor, charted that a small erosion was present, and prescribed estrogen cream.
The patient continued to report pain, discomfort, pressure, difficulty voiding urine, continued incontinence, vaginal discharge, scarring, infection, odor, and bleeding.
PATIENT’S CLAIM The polypropylene mesh used during the midurethral sling procedure has been shown to be incompatible with human tissue. It promotes an immune response, which stimulates degradation of the pelvic tissue and can contribute to the development of severe adverse reactions to the mesh. Ethicon negligently designed, manufactured, marketed, labeled, and packaged the pelvic mesh products.
DEFENDANTS’ DEFENSE Proper warnings were provided about the health risks associated with polypropylene mesh products. The medical device was not properly sized.
VERDICT A Texas jury rejected the patient’s claims that Ethicon did not provide proper warnings about the sling’s health risks and declined to award punitive damages.
However, the jury decided that the mesh implant was defectively designed, and returned a $1.2 million verdict against Ethicon.
Was suspected bowel injury treated properly?
A 40-year-old woman was referred to an ObGyn after reporting abnormal uterine bleeding to her primary care physician. The patient had very light menses every few weeks. The ObGyn performed an ablation procedure, without relief. A month later, the ObGyn performed robot-assisted laparoscopic hysterectomy. The next day, the patient reported abdominal pain. Suspecting a bowel injury, the ObGyn ordered a CT scan; the bowel appeared normal, so the ObGyn referred the patient to a surgeon. During exploratory laparotomy, the surgeon found and repaired a bowel injury. The patient developed significant complications from a necrotizing infection that included respiratory distress and ongoing wound care.
PATIENT’S CLAIM Conservative treatment should have been offered before surgery. The ObGyn should have waited longer after the ablation procedure before doing the hysterectomy. The ObGyn should have checked for a possible bowel injury before closing the hysterectomy.
PHYSICIAN’S DEFENSE The bowel injury is a known complication of the procedure and was recognized and repaired in a timely manner.
VERDICT A Kentucky defense verdict was returned.
Pap smear improperly interpreted: Woman dies from cervical cancer
A 37-year-old woman underwent a pap smear in 2008 that was read by a cytotechnologist as normal. Two years later, the patient was found to have a golf-ball–sized cancerous tumor. She died from cervical cancer in 2011.
ESTATE’S CLAIM The cytotechnologist was negligent in misreading the 2008 Pap smear. If treatment had been started in 2008, the cancer could have been resolved with a simple conization biopsy.
DEFENDANTS’ DEFENSE The Pap smear interpretation was reasonable. The cancer could not have been diagnosed in 2008. The patient was at fault for failing to follow-up Pap smears during the next 2 years.
VERDICT After assigning 75% fault to the cytotechnologist and 25% fault to the patient, a Florida jury returned a $20,870,200 verdict, which was reduced to $15,816,699.
Disastrous off-label use of anticoagulation
When a pelvic abscess was found, a 50-year-old woman was admitted to the hospital for treatment. She was taking warfarin due to a history of venous thromboembolism.
Before the procedure, her physicians attempted to temporarily reverse her anticoagulation by administering Factor IX Complex (Profilnine SD, Grifols Biologicals). The dose ordered for the patient was nearly double the maximum recommended weight-based dose. Almost immediately after receiving the infusion, the patient went into cardiopulmonary arrest and died. An autopsy found the cause of death to be pulmonary emboli (PE).
ESTATE’S CLAIM An excessive dose of Profilnine caused PE. At the time of the incident, Profilnine was not FDA approved for warfarin reversal, although some off-label uses were recognized in emergent situations, such as intracranial bleeds.
DEFENDANTS’ DEFENSE The case was settled during the trial.
VERDICT A $1.25 million Virginia settlement was reached.
Vesicovaginal fistula from ureteral injury
At a women’s health clinic, a patient reported continuous, heavy vaginal bleeding; pain; and shortness of breath when walking. She had a history of endometritis and multiple abdominal surgeries. Examination disclosed a profuse vaginal discharge, a normal cervix, and an enlarged uterus. The patient consented to abdominal hysterectomy and bilateral salpingo-oophorectomy performed by an ObGyn assisted by a resident.
During surgery, the ObGyn found that the patient’s uterus was at 16 to 20 weeks’ gestation size, with multiple serosal uterine fibroids and frank pus and necrosed fibroid tumors within the uterine cavity. The procedure took longer than planned because of extensive adhesions. After surgery, the patient was anemic and was given a beta-blocker for tachycardia. She was discharged 3 days later with 48 hours’ worth of intravenous antibiotics.
A month later, the patient reported urinary incontinence. She saw a urologist, who found a vesicovaginal fistula. The patient underwent nephrostomy-tube placement. Right ureterolysis and a right ureteral reimplant was performed 4 months later.
PATIENT’S CLAIM The ObGyn injured the right ureter during surgery.
DEFENDANTS’ DEFENSE The ureter injury is a known risk of the procedure. The injury was due to an infection or delayed effects of ischemia. The patient had a good recovery with no residual injury.
VERDICT A Michigan defense verdict was returned.
Why did mother die after delivering twins?
After a 35-year-old woman gave birth to twins by cesarean delivery, she died. At autopsy, 4 liters of blood were found in her abdomen.
ESTATE’S CLAIM The ObGyn failed to recognize and treat an arterial or venous bleed during surgery.
DEFENDANTS’ DEFENSE The patient died from amniotic fluid embolism. Autopsy results showed right ventricular heart failure, respiratory failure, and disseminated intravascular coagulation.
VERDICT A Florida defense verdict was returned.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Was fetus’ wrist injured during cesarean delivery?
At 34 weeks’ gestation, a 39-year-old woman went to the hospital in preterm labor. Her history included a prior cesarean delivery. Ultrasonography (US) showed that the fetus was in a double-footling breech position. The ObGyn decided to perform a cesarean delivery when the fetal heart-rate monitor indicated distress.
After making a midline incision through the earlier scar, the ObGyn created a low transverse uterine incision with a scalpel. The mother’s uterus was thick because labor had not progressed. When the ObGyn was unable to deliver the baby through the low transverse incision, she performed a T-extension of the incision using bandage scissors while placing her free hand inside the uterus to shield the fetus from injury. After extensive manipulation, the baby was delivered and immediately handed to a neonatologist. After surgery, the neonatologist told the mother that the baby had sustained two lacerations to the ulnar side of the right wrist. The newborn was airlifted to another hospital for treatment of sepsis. There, an orthopedic hand surgeon examined the child and determined that the lacerations were superficial and only required sutures. The orthopedist saw the infant a month later and believed there was no significant wrist injury.
When the child began preschool, she started to experience cold intolerance and difficulty writing with her right hand. The child was referred to a pediatric neurologist, who found no nerve damage and ordered occupational therapy.
The original orthopedic surgeon examined the child when she was 7 years old and determined that the flexor carpi ulnaris tendon had been completely severed with a partial injury to the ulnar nerve. He recommended a return visit at age 14 for full assessment of the wrist injury.
PARENTS’ CLAIM The ObGyn did not properly shield the fetus when performing the T-extension incision during cesarean delivery. The child’s weakness will increase with age, ruling out some occupations.
PHYSICIAN’S DEFENSE The ObGyn was not negligent; she had provided adequate protection of the fetus during both incisions.
VERDICT An Illinois defense verdict was returned.
Woman dies after tubal ligation
After a 42-year-old woman underwent tubal ligation, her surgeon was concerned about a possible bowel perforation and admitted her to the hospital. The next morning, a computed tomography (CT) scan of the abdomen did not reveal bowel injury.
That afternoon, when the patient reported shortness of breath, the surgeon called the hospitalist with concern for pulmonary embolism (PE). The hospitalist immediately ordered a CT scan of the chest, initiated PE protocol, and wrote “r/o PE” on the chart. A radiologist reminded the hospitalist of the earlier CT scan with concern for kidney damage from another dye study. The hospitalist cancelled the CT scan and PE protocol. After waiting 17 hours to run any further tests, a CT scan revealed massive bilateral PE. The patient was transferred to the ICU, but died the next day.
PATIENT’S CLAIM The 17-hour delay was negligent.
PHYSICIAN’S DEFENSE There was no negligence. The patient died of septic shock, not PE.
VERDICT A $4 million Virginia verdict was returned.
Child born without hand and forearm
During prenatal care, a mother underwent US at 20 and 36 weeks; both studies were reported as normal. The child was born missing his left hand and part of his left forearm due to a congenital amputation. The child will require prosthetics for life.
PATIENT’S CLAIM The condition should have been seen during prenatal US; an abortion was still an option at 20 weeks.
DEFENDANTS’ DEFENSE US was properly performed and evaluated. It can be difficult to differentiate the right from left extremities.
VERDICT A California defense verdict was returned.
After starting Yasmin, woman has stroke with permanent paralysis: $16.5M total award
When a 37-year-old woman reported irregular menstruation, her ObGyn prescribed drospirenone/ethinyl estradiol (Yasmin; Bayer). Thirteen days after starting the drug, the patient had a stroke. She is paralyzed on her left side, has limited ability to speak, cannot use her left arm and leg, and requires 24-hour care.
PATIENT’S CLAIM The ObGyn should have recognized that Yasmin was not appropriate for this patient because of the drug’s clotting risks. The patient’s risk factors included her age (over 35), borderline hypertension, overweight, history of smoking, and high cholesterol. The ObGyn should have offered safer alternatives, such as a progesterone-only pill. The US Food and Drug Administration (FDA) issued a safety warning that all drospirenone-containing drugs may be associated with a higher risk of venous thrombosis during the first 6 months of use.
DEFENDANTS’ DEFENSE According to Bayer, Yasmin is safe, and remains on the market. It was an appropriate drug to treat her irregular bleeding.
VERDICT Claims against the medical center that referred the patient to the ObGyn were settled for $2.5 million before trial. A $14 million Illinois verdict was returned against the ObGyn, for a total award of $16.5 million.
Who is at fault when pelvic mesh erodes?
In January 2011, an ObGyn implanted the Gynecare TVT Obturator System (TVT‑O; Ethicon) during a midurethral sling procedure to treat stress urinary incontinence (SUI) in a woman in her 60s. Shortly thereafter, the ObGyn left practice because of early-onset Alzheimer’s disease, and the patient’s care was taken over by a gynecologist.
At the 2-month postoperative visit, the gynecologist found that the mesh had eroded into the patient’s vagina. The gynecologist simply cut the mesh with a scissor, charted that a small erosion was present, and prescribed estrogen cream.
The patient continued to report pain, discomfort, pressure, difficulty voiding urine, continued incontinence, vaginal discharge, scarring, infection, odor, and bleeding.
PATIENT’S CLAIM The polypropylene mesh used during the midurethral sling procedure has been shown to be incompatible with human tissue. It promotes an immune response, which stimulates degradation of the pelvic tissue and can contribute to the development of severe adverse reactions to the mesh. Ethicon negligently designed, manufactured, marketed, labeled, and packaged the pelvic mesh products.
DEFENDANTS’ DEFENSE Proper warnings were provided about the health risks associated with polypropylene mesh products. The medical device was not properly sized.
VERDICT A Texas jury rejected the patient’s claims that Ethicon did not provide proper warnings about the sling’s health risks and declined to award punitive damages.
However, the jury decided that the mesh implant was defectively designed, and returned a $1.2 million verdict against Ethicon.
Was suspected bowel injury treated properly?
A 40-year-old woman was referred to an ObGyn after reporting abnormal uterine bleeding to her primary care physician. The patient had very light menses every few weeks. The ObGyn performed an ablation procedure, without relief. A month later, the ObGyn performed robot-assisted laparoscopic hysterectomy. The next day, the patient reported abdominal pain. Suspecting a bowel injury, the ObGyn ordered a CT scan; the bowel appeared normal, so the ObGyn referred the patient to a surgeon. During exploratory laparotomy, the surgeon found and repaired a bowel injury. The patient developed significant complications from a necrotizing infection that included respiratory distress and ongoing wound care.
PATIENT’S CLAIM Conservative treatment should have been offered before surgery. The ObGyn should have waited longer after the ablation procedure before doing the hysterectomy. The ObGyn should have checked for a possible bowel injury before closing the hysterectomy.
PHYSICIAN’S DEFENSE The bowel injury is a known complication of the procedure and was recognized and repaired in a timely manner.
VERDICT A Kentucky defense verdict was returned.
Pap smear improperly interpreted: Woman dies from cervical cancer
A 37-year-old woman underwent a pap smear in 2008 that was read by a cytotechnologist as normal. Two years later, the patient was found to have a golf-ball–sized cancerous tumor. She died from cervical cancer in 2011.
ESTATE’S CLAIM The cytotechnologist was negligent in misreading the 2008 Pap smear. If treatment had been started in 2008, the cancer could have been resolved with a simple conization biopsy.
DEFENDANTS’ DEFENSE The Pap smear interpretation was reasonable. The cancer could not have been diagnosed in 2008. The patient was at fault for failing to follow-up Pap smears during the next 2 years.
VERDICT After assigning 75% fault to the cytotechnologist and 25% fault to the patient, a Florida jury returned a $20,870,200 verdict, which was reduced to $15,816,699.
Disastrous off-label use of anticoagulation
When a pelvic abscess was found, a 50-year-old woman was admitted to the hospital for treatment. She was taking warfarin due to a history of venous thromboembolism.
Before the procedure, her physicians attempted to temporarily reverse her anticoagulation by administering Factor IX Complex (Profilnine SD, Grifols Biologicals). The dose ordered for the patient was nearly double the maximum recommended weight-based dose. Almost immediately after receiving the infusion, the patient went into cardiopulmonary arrest and died. An autopsy found the cause of death to be pulmonary emboli (PE).
ESTATE’S CLAIM An excessive dose of Profilnine caused PE. At the time of the incident, Profilnine was not FDA approved for warfarin reversal, although some off-label uses were recognized in emergent situations, such as intracranial bleeds.
DEFENDANTS’ DEFENSE The case was settled during the trial.
VERDICT A $1.25 million Virginia settlement was reached.
Vesicovaginal fistula from ureteral injury
At a women’s health clinic, a patient reported continuous, heavy vaginal bleeding; pain; and shortness of breath when walking. She had a history of endometritis and multiple abdominal surgeries. Examination disclosed a profuse vaginal discharge, a normal cervix, and an enlarged uterus. The patient consented to abdominal hysterectomy and bilateral salpingo-oophorectomy performed by an ObGyn assisted by a resident.
During surgery, the ObGyn found that the patient’s uterus was at 16 to 20 weeks’ gestation size, with multiple serosal uterine fibroids and frank pus and necrosed fibroid tumors within the uterine cavity. The procedure took longer than planned because of extensive adhesions. After surgery, the patient was anemic and was given a beta-blocker for tachycardia. She was discharged 3 days later with 48 hours’ worth of intravenous antibiotics.
A month later, the patient reported urinary incontinence. She saw a urologist, who found a vesicovaginal fistula. The patient underwent nephrostomy-tube placement. Right ureterolysis and a right ureteral reimplant was performed 4 months later.
PATIENT’S CLAIM The ObGyn injured the right ureter during surgery.
DEFENDANTS’ DEFENSE The ureter injury is a known risk of the procedure. The injury was due to an infection or delayed effects of ischemia. The patient had a good recovery with no residual injury.
VERDICT A Michigan defense verdict was returned.
Why did mother die after delivering twins?
After a 35-year-old woman gave birth to twins by cesarean delivery, she died. At autopsy, 4 liters of blood were found in her abdomen.
ESTATE’S CLAIM The ObGyn failed to recognize and treat an arterial or venous bleed during surgery.
DEFENDANTS’ DEFENSE The patient died from amniotic fluid embolism. Autopsy results showed right ventricular heart failure, respiratory failure, and disseminated intravascular coagulation.
VERDICT A Florida defense verdict was returned.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Failure to spot CHF leads to heart transplant
Failure to spot CHF leads to heart transplant
A 49-YEAR-OLD MAN SOUGHT TREATMENT AT AN URGENT CARE FACILITY after having shortness of breath every morning for 2 weeks. His heart rate was 119 beats/min, his blood pressure was 170/101 mm Hg, and he did not have chest pain. An electrocardiogram (EKG) was abnormal and chest x-ray showed fluid in the lung. The patient was diagnosed with pneumonia, prescribed antibiotics, and told to follow up with his physician. A follow-up chest x-ray 2 weeks later showed an enlarged heart and more fluid in the lung. A computed tomography scan indicated congestive heart failure and an EKG showed signs of a heart attack. The patient underwent a heart transplant and requires immunosuppressants.
PLAINTIFF'S CLAIM If the physician at the urgent care facility had noticed the patient’s enlarged heart, there would have been less heart damage, and the patient might have required a bypass, rather than a transplant.
THE DEFENSE No information about the defense is available.
VERDICT $1 million New Jersey verdict.
COMMENT When evaluating shortness of breath, always think lungs and heart until you have a definite diagnosis. Remember that neurological disease can present with shortness of breath, too. Consider amyotrophic lateral sclerosis, Guillain-Barré syndrome, and myasthenia gravis.
Infant suffers brain injury after delayed lab results
PARENTS BROUGHT THEIR 2-WEEK-OLD DAUGHTER TO THE EMERGENCY DEPARTMENT (ED) after she had missed several feedings and was short of breath. The ED physician ordered blood tests, but discharged the patient before receiving the results and told the parents to follow up with the infant’s pediatrician. Blood work subsequently revealed that the child had a Group B streptococcus infection, but by the time these results were communicated to the parents and treatment had begun, the infant had developed meningitis. She suffered brain injury, and was diagnosed with cerebral palsy.
PLAINTIFF'S CLAIM There was a delay in the diagnosis and treatment of the infant. Blood test results showing a bacterial infection were available the morning after discharge, but instead of notifying the parents, an additional blood culture was ordered to determine the type of bacteria present. The parents were then contacted 6 hours after the bacteria was identified as Group B streptococcus.
THE DEFENSE The defendants denied any negligence, although a nurse who cared for the infant claimed she had expressed concerns about the decision to discharge the patient.
VERDICT $7.15 million Maryland verdict.
COMMENT In newborns, the differential diagnosis for shortness of breath widens to include infection. In this case, I suspect the problem was a lack of tight follow-up, which can lead to bad outcomes—especially in newborns.
Failure to spot CHF leads to heart transplant
A 49-YEAR-OLD MAN SOUGHT TREATMENT AT AN URGENT CARE FACILITY after having shortness of breath every morning for 2 weeks. His heart rate was 119 beats/min, his blood pressure was 170/101 mm Hg, and he did not have chest pain. An electrocardiogram (EKG) was abnormal and chest x-ray showed fluid in the lung. The patient was diagnosed with pneumonia, prescribed antibiotics, and told to follow up with his physician. A follow-up chest x-ray 2 weeks later showed an enlarged heart and more fluid in the lung. A computed tomography scan indicated congestive heart failure and an EKG showed signs of a heart attack. The patient underwent a heart transplant and requires immunosuppressants.
PLAINTIFF'S CLAIM If the physician at the urgent care facility had noticed the patient’s enlarged heart, there would have been less heart damage, and the patient might have required a bypass, rather than a transplant.
THE DEFENSE No information about the defense is available.
VERDICT $1 million New Jersey verdict.
COMMENT When evaluating shortness of breath, always think lungs and heart until you have a definite diagnosis. Remember that neurological disease can present with shortness of breath, too. Consider amyotrophic lateral sclerosis, Guillain-Barré syndrome, and myasthenia gravis.
Infant suffers brain injury after delayed lab results
PARENTS BROUGHT THEIR 2-WEEK-OLD DAUGHTER TO THE EMERGENCY DEPARTMENT (ED) after she had missed several feedings and was short of breath. The ED physician ordered blood tests, but discharged the patient before receiving the results and told the parents to follow up with the infant’s pediatrician. Blood work subsequently revealed that the child had a Group B streptococcus infection, but by the time these results were communicated to the parents and treatment had begun, the infant had developed meningitis. She suffered brain injury, and was diagnosed with cerebral palsy.
PLAINTIFF'S CLAIM There was a delay in the diagnosis and treatment of the infant. Blood test results showing a bacterial infection were available the morning after discharge, but instead of notifying the parents, an additional blood culture was ordered to determine the type of bacteria present. The parents were then contacted 6 hours after the bacteria was identified as Group B streptococcus.
THE DEFENSE The defendants denied any negligence, although a nurse who cared for the infant claimed she had expressed concerns about the decision to discharge the patient.
VERDICT $7.15 million Maryland verdict.
COMMENT In newborns, the differential diagnosis for shortness of breath widens to include infection. In this case, I suspect the problem was a lack of tight follow-up, which can lead to bad outcomes—especially in newborns.
Failure to spot CHF leads to heart transplant
A 49-YEAR-OLD MAN SOUGHT TREATMENT AT AN URGENT CARE FACILITY after having shortness of breath every morning for 2 weeks. His heart rate was 119 beats/min, his blood pressure was 170/101 mm Hg, and he did not have chest pain. An electrocardiogram (EKG) was abnormal and chest x-ray showed fluid in the lung. The patient was diagnosed with pneumonia, prescribed antibiotics, and told to follow up with his physician. A follow-up chest x-ray 2 weeks later showed an enlarged heart and more fluid in the lung. A computed tomography scan indicated congestive heart failure and an EKG showed signs of a heart attack. The patient underwent a heart transplant and requires immunosuppressants.
PLAINTIFF'S CLAIM If the physician at the urgent care facility had noticed the patient’s enlarged heart, there would have been less heart damage, and the patient might have required a bypass, rather than a transplant.
THE DEFENSE No information about the defense is available.
VERDICT $1 million New Jersey verdict.
COMMENT When evaluating shortness of breath, always think lungs and heart until you have a definite diagnosis. Remember that neurological disease can present with shortness of breath, too. Consider amyotrophic lateral sclerosis, Guillain-Barré syndrome, and myasthenia gravis.
Infant suffers brain injury after delayed lab results
PARENTS BROUGHT THEIR 2-WEEK-OLD DAUGHTER TO THE EMERGENCY DEPARTMENT (ED) after she had missed several feedings and was short of breath. The ED physician ordered blood tests, but discharged the patient before receiving the results and told the parents to follow up with the infant’s pediatrician. Blood work subsequently revealed that the child had a Group B streptococcus infection, but by the time these results were communicated to the parents and treatment had begun, the infant had developed meningitis. She suffered brain injury, and was diagnosed with cerebral palsy.
PLAINTIFF'S CLAIM There was a delay in the diagnosis and treatment of the infant. Blood test results showing a bacterial infection were available the morning after discharge, but instead of notifying the parents, an additional blood culture was ordered to determine the type of bacteria present. The parents were then contacted 6 hours after the bacteria was identified as Group B streptococcus.
THE DEFENSE The defendants denied any negligence, although a nurse who cared for the infant claimed she had expressed concerns about the decision to discharge the patient.
VERDICT $7.15 million Maryland verdict.
COMMENT In newborns, the differential diagnosis for shortness of breath widens to include infection. In this case, I suspect the problem was a lack of tight follow-up, which can lead to bad outcomes—especially in newborns.
Impending stroke chalked up to carpal tunnel syndrome
Impending stroke chalked up to carpal tunnel syndrome
A WOMAN WENT TO HER PHYSICIAN COMPLAINING OF DIZZINESS, blurred vision, numbness, tingling in her hands and feet, and other symptoms. The physician diagnosed carpal tunnel syndrome. The patient visited her physician a second time, and a day later, suffered a stroke and died.
PLAINTIFF The patient specifically asked her physician if she was having a stroke and her physician told her No.
THE DEFENSE No information about the defense is available.
VERDICT $907,486 Kansas verdict.
COMMENT Certainly carpal tunnel syndrome is not sufficient to explain all of this patient’s symptoms—especially dizziness and blurred vision—but the details on this case are limited. If the patient did in fact express concern about a possible stroke, it was incumbent upon the physician to evaluate carefully and either diagnose that condition or rule it out.
Rather than coming too late, Rx for methadone came too soon
A 34-YEAR-OLD MAN ADDICTED TO OXYCODONE AND OTHER PAIN MEDICATIONS as the result of a work-related injury 10 years earlier sought treatment for his addiction from a family physician (FP) while visiting Kentucky. The patient also was abusing alprazolam. The FP administered a drug test but prescribed methadone, 180 10-mg pills, before receiving the results. The next day, the drug screen returned positive for multiple drugs, including opiates and cannabinoids. The FP’s staff tried to reach the patient, but was unsuccessful. The patient was found dead a few hours later after overdosing on a combination of methadone and alprazolam. Although 64 methadone pills were missing, the patient could not have taken all of them because only a therapeutic level of methadone was found in his system.
PLAINTIFF’S CLAIM The physician should have waited to receive the results of the drug screen before prescribing methadone. Drug Enforcement Administration guidelines allow prescription of methadone for addiction only if a patient is in withdrawal and in the process of being admitted to a treatment facility. There was no proof of withdrawal symptoms.
THE DEFENSE The treatment was reasonable and compassionate. The patient was at fault for abusing narcotics.
VERDICT $204,500 Kentucky verdict.
Could a proper history have spared this patient multiple surgeries?
A 13-YEAR-OLD CAME TO THE EMERGENCY DEPARTMENT (ED) with left knee pain and fever. He was diagnosed with a quadriceps strain and discharged. The next morning the patient still had knee pain and sought treatment from an FP, who diagnosed a sprained knee. At this visit, the patient’s temperature was normal. Three days later, the patient went to another ED with a high fever and knee pain so severe that he couldn’t walk. Blood culture revealed methicillin-resistant Staphylococcus aureus (MRSA) in the knee, which quickly spread. The patient was hospitalized and required 17 surgeries.
PLAINTIFF’S CLAIM The FP should have ordered blood work and recognized the signs of infection. MRSA had been present at least 4 days before it was diagnosed.
THE DEFENSE The patient did not have a diagnosable infection the day the physician saw him and his condition had progressed over the following 3 days.
VERDICT $2.1 million Illinois verdict.
COMMENT This case reminds me of the necessity of obtaining a history of the mechanism of injury for joint pain. Absence of a definite cause should have led to a wider differential diagnosis.
Impending stroke chalked up to carpal tunnel syndrome
A WOMAN WENT TO HER PHYSICIAN COMPLAINING OF DIZZINESS, blurred vision, numbness, tingling in her hands and feet, and other symptoms. The physician diagnosed carpal tunnel syndrome. The patient visited her physician a second time, and a day later, suffered a stroke and died.
PLAINTIFF The patient specifically asked her physician if she was having a stroke and her physician told her No.
THE DEFENSE No information about the defense is available.
VERDICT $907,486 Kansas verdict.
COMMENT Certainly carpal tunnel syndrome is not sufficient to explain all of this patient’s symptoms—especially dizziness and blurred vision—but the details on this case are limited. If the patient did in fact express concern about a possible stroke, it was incumbent upon the physician to evaluate carefully and either diagnose that condition or rule it out.
Rather than coming too late, Rx for methadone came too soon
A 34-YEAR-OLD MAN ADDICTED TO OXYCODONE AND OTHER PAIN MEDICATIONS as the result of a work-related injury 10 years earlier sought treatment for his addiction from a family physician (FP) while visiting Kentucky. The patient also was abusing alprazolam. The FP administered a drug test but prescribed methadone, 180 10-mg pills, before receiving the results. The next day, the drug screen returned positive for multiple drugs, including opiates and cannabinoids. The FP’s staff tried to reach the patient, but was unsuccessful. The patient was found dead a few hours later after overdosing on a combination of methadone and alprazolam. Although 64 methadone pills were missing, the patient could not have taken all of them because only a therapeutic level of methadone was found in his system.
PLAINTIFF’S CLAIM The physician should have waited to receive the results of the drug screen before prescribing methadone. Drug Enforcement Administration guidelines allow prescription of methadone for addiction only if a patient is in withdrawal and in the process of being admitted to a treatment facility. There was no proof of withdrawal symptoms.
THE DEFENSE The treatment was reasonable and compassionate. The patient was at fault for abusing narcotics.
VERDICT $204,500 Kentucky verdict.
Could a proper history have spared this patient multiple surgeries?
A 13-YEAR-OLD CAME TO THE EMERGENCY DEPARTMENT (ED) with left knee pain and fever. He was diagnosed with a quadriceps strain and discharged. The next morning the patient still had knee pain and sought treatment from an FP, who diagnosed a sprained knee. At this visit, the patient’s temperature was normal. Three days later, the patient went to another ED with a high fever and knee pain so severe that he couldn’t walk. Blood culture revealed methicillin-resistant Staphylococcus aureus (MRSA) in the knee, which quickly spread. The patient was hospitalized and required 17 surgeries.
PLAINTIFF’S CLAIM The FP should have ordered blood work and recognized the signs of infection. MRSA had been present at least 4 days before it was diagnosed.
THE DEFENSE The patient did not have a diagnosable infection the day the physician saw him and his condition had progressed over the following 3 days.
VERDICT $2.1 million Illinois verdict.
COMMENT This case reminds me of the necessity of obtaining a history of the mechanism of injury for joint pain. Absence of a definite cause should have led to a wider differential diagnosis.
Impending stroke chalked up to carpal tunnel syndrome
A WOMAN WENT TO HER PHYSICIAN COMPLAINING OF DIZZINESS, blurred vision, numbness, tingling in her hands and feet, and other symptoms. The physician diagnosed carpal tunnel syndrome. The patient visited her physician a second time, and a day later, suffered a stroke and died.
PLAINTIFF The patient specifically asked her physician if she was having a stroke and her physician told her No.
THE DEFENSE No information about the defense is available.
VERDICT $907,486 Kansas verdict.
COMMENT Certainly carpal tunnel syndrome is not sufficient to explain all of this patient’s symptoms—especially dizziness and blurred vision—but the details on this case are limited. If the patient did in fact express concern about a possible stroke, it was incumbent upon the physician to evaluate carefully and either diagnose that condition or rule it out.
Rather than coming too late, Rx for methadone came too soon
A 34-YEAR-OLD MAN ADDICTED TO OXYCODONE AND OTHER PAIN MEDICATIONS as the result of a work-related injury 10 years earlier sought treatment for his addiction from a family physician (FP) while visiting Kentucky. The patient also was abusing alprazolam. The FP administered a drug test but prescribed methadone, 180 10-mg pills, before receiving the results. The next day, the drug screen returned positive for multiple drugs, including opiates and cannabinoids. The FP’s staff tried to reach the patient, but was unsuccessful. The patient was found dead a few hours later after overdosing on a combination of methadone and alprazolam. Although 64 methadone pills were missing, the patient could not have taken all of them because only a therapeutic level of methadone was found in his system.
PLAINTIFF’S CLAIM The physician should have waited to receive the results of the drug screen before prescribing methadone. Drug Enforcement Administration guidelines allow prescription of methadone for addiction only if a patient is in withdrawal and in the process of being admitted to a treatment facility. There was no proof of withdrawal symptoms.
THE DEFENSE The treatment was reasonable and compassionate. The patient was at fault for abusing narcotics.
VERDICT $204,500 Kentucky verdict.
Could a proper history have spared this patient multiple surgeries?
A 13-YEAR-OLD CAME TO THE EMERGENCY DEPARTMENT (ED) with left knee pain and fever. He was diagnosed with a quadriceps strain and discharged. The next morning the patient still had knee pain and sought treatment from an FP, who diagnosed a sprained knee. At this visit, the patient’s temperature was normal. Three days later, the patient went to another ED with a high fever and knee pain so severe that he couldn’t walk. Blood culture revealed methicillin-resistant Staphylococcus aureus (MRSA) in the knee, which quickly spread. The patient was hospitalized and required 17 surgeries.
PLAINTIFF’S CLAIM The FP should have ordered blood work and recognized the signs of infection. MRSA had been present at least 4 days before it was diagnosed.
THE DEFENSE The patient did not have a diagnosable infection the day the physician saw him and his condition had progressed over the following 3 days.
VERDICT $2.1 million Illinois verdict.
COMMENT This case reminds me of the necessity of obtaining a history of the mechanism of injury for joint pain. Absence of a definite cause should have led to a wider differential diagnosis.
Blue towel left in abdomen: $7.2M verdict
Blue towel left in abdomen: $7.2M verdict
When a 61-year-old woman underwent laparoscopic hysterectomy, her gynecologist, Dr. A, was assisted by another gynecologist (Dr. B), a nurse, and a technician. When Dr. A noted that the uterine artery had been injured, he converted to an open procedure, retracted the bowel, repaired the artery, and completed the operation.
Postdischarge, the patient was febrile and developed abdominal pain and an odorous vaginal discharge. A month later, exploratory surgery revealed a retained blue towel that had been used for bowel retraction. The patient required open healing of the surgical wound and a temporary colostomy. She developed an incisional hernia after colostomy reversal, and hernia repair required resection of a small portion of the bowel.
PATIENT’S CLAIM It was negligent to use a blue towel to retract the bowel. The towel should have been removed from her abdomen before closure.
DEFENDANTS’ DEFENSE The technician claimed that she did not provide the towel, did not see the towel used, and that she was not told that the towel had to be tracked. She noted that its color indicated that it lacked a radiopaque tag, and that hospital policy forbade use of untagged towels in an open wound.
Dr. A claimed that he specifically requested a blue towel because it was absorbent, that the technician provided the towel, and that the towel’s use prevented the patient from bleeding to death.
VERDICT A $7.2 million New York verdict was returned against both gynecologists and the hospital as the technician’s employer.
MISCARRIAGE AFTER D&C
A few days after a woman thought she miscarried, her family practi-tioner (FP) performed a dilation and curettage (D&C).
The patient was at work 12 days later when she expelled a fully formed 14-week fetus into a toilet. She was taken to the emergency department (ED), where the cord was cut. Later that day, she passed placental tissue; a repeat D&C was performed the next day.
PATIENT'S CLAIM The FP did not properly perform the first D&C. Although the pathology report was available to the FP prior to the patient’s postoperative visit, the FP failed to inform the patient that no fetal parts had been extracted.
PHYSICIAN’S DEFENSE Because the FP thought that the fetus had been passed prior to the D&C, she believed the pathology report was appropriate.
The patient had been informed of the possibility of retained products of conception after the D&C. The FP had ordered a blood pregnancy test that would have revealed the presence of retained products of conception, but the patient did not have the test. The patient did not contact the FP to report symptoms that felt like labor pains on the day that she passed the fetus.
VERDICT A bench trial resulted in a $51,000 California verdict.
PREGNANT WOMAN COMPLAINS OF LEG PAIN; DIES OF DVT
A 23-year-old woman went to the ED with pain and swelling in her lower left leg and calf. The symptoms were reported to her ObGyn, who examined and then discharged her within a few hours, with instructions to come for her regularly scheduled prenatal visit.
The patient died 2 weeks later. The cause of death was determined to be a pulmonary embolus from a thrombus of the left popliteal vein.
ESTATE’S CLAIM The ObGyn was negligent in failing to test the patient for thrombosis in her left leg when she was in the ED or several days later at the office, when she continued to report leg pain.
PHYSICIAN’S DEFENSE The patient did not have signs of thrombosis at the ED or at the subsequent office visit. The pathologist reported that the clot that caused the embolus appeared fresh. The ObGyn surmised that it had formed after the patient’s last appointment.
VERDICT A Texas defense verdict was returned.
Mother took topiramate; child born with cleft lip and palate: $3M verdict
When a woman learned she was pregnant in December 2007, she was taking topiramate (Topamax) to treat migraine headaches. She discussed tapering off but not discontinuing topiramate usage with her neurologist. The patient’s ObGyn told her that topiramate was safe to take during pregnancy. The child was born with a cleft lip and palate.
PARENTS’ CLAIM Janssen Pharmaceuticals, manufacturer of Topamax, failed to provide adequate warnings about the potential risks associated with Topamax until labeling was changed in March 2011. Janssen knew of potential birth defects associated with Topamax use during pregnancy more than a decade before the labeling change; Janssen’s associate director of regulatory affairs had testified in an earlier hearing that there was knowledge of related birth defects as early as 1996.
DEFENDANTS’ DEFENSE There is uncertainty as to whether exposure to Topamax during pregnancy causes birth defects. The neurologist had warned the patient of possible risks associated with taking Topamax during pregnancy, but the patient had refused to discontinue the drug.
VERDICT A $3 million Pennsylvania verdict was returned.
Related articles:
• Is it time to rethink the use of oral contraceptives in premenopausal women with migraine? Anne H. Calhoun, MD (Audiocast; October 2013)
• How to choose a contraceptive for a patient who has headaches. Kristina M. Tocce, MD; Stephanie B. Teal, MD, MPH (February 2011)
• The gynecologist’s role in managing menstrual migraine. Anne H. Calhoun, MD (April 2010)
WAS MOTHER’S HISTORY OF INCOMPETENT CERVIX IGNORED?
Early in her second pregnancy, a woman told her ObGyn that she had previously miscarried due to an incompetent cervix.
At 24 weeks’ gestation, the patient was admitted to the hospital with back and pelvic pain and vaginal bleeding. Shortly after admission, the ObGyn performed a vaginal examination and ordered ultrasonography (US), which showed that the fetus was in the transverse position and the membranes were bulging.
The ObGyn performed an emergency cesarean delivery, but the premature infant died within 2 hours.
PARENTS’ CLAIM The ObGyn should have performed a cervical cerclage because of the mother’s history of an incompetent cervix. The mother should have been placed on bed rest and monitored every 2 weeks for cervical dilation.
PHYSICIAN’S DEFENSE The patient underwent regular prenatal evaluations for an incompetent cervix, and the findings were always normal.
VERDICT A Florida defense verdict was returned.
Related article:
A stepwise approach to cervical cerclage. Katrin Karl, MD; Michael Katz, MD (Surgical Technique; June 2012)
ObGyn unresponsive to patient’s postsurgical phone calls
In 2009, a 50-year-old woman reported occasional right lower quadrant pain to her ObGyn. US results were normal. The menopausal patient’s history included three cesarean deliveries, a total abdominal hysterectomy, and a laparoscopic ovarian cystectomy.
When the patient saw her ObGyn in December 2010, she reported intermittent, progressive right lower quadrant pain that radiated down her right leg. She also reported urine loss with coughing or sneezing, and slight pain on intercourse. The ObGyn prescribed oxybutynin chloride (Ditropan) to treat the patient’s incontinence.
Three weeks later, the patient reported bilateral lower quadrant pain to her ObGyn, with minor improvement in incontinence.
The ObGyn performed bilateral salpingo-oophorectomy (BSO) in January 2011. Surgery took 3.5 hours due to extensive adhesiolysis.
After discharge, the patient felt ill and vomited. She attempted to reach the ObGyn by phone several times. That evening, the ObGyn prescribed a suppository to treat nausea and vomiting.
The patient went to the ED later that night and was found to have a perforated colon. Emergency surgery to repair the injury included creation of a colostomy, which was repaired 20 months later.
PATIENT’S CLAIM A proper workup of her symptoms was not performed; BSO was unnecessary. The ObGyn was negligent for failing to respond in a timely manner to her post-discharge phone calls, and did not properly evaluate her postoperative symptoms.
PHYSICIAN’S DEFENSE BSO was warranted. Colon injury is a known complication of the procedure.
VERDICT A $716,976 California verdict was returned, but was reduced to $591,967 under the state cap.
Who delayed delivery? $32.8M verdict for child with CP
An 18-year-old woman at 38 weeks’ gestation went to the hospital in labor. After 3.5 hours, the fetal heart rate dropped to 60 bpm. A nurse repositioned the patient, administered oxygen, and increased intravenous fluids. When the nurse rang the emergency call bell, a second nurse responded. Eighteen minutes after the fetal heart rate first dropped, a nurse rang the call bell again and the on-call ObGyn appeared.
The ObGyn performed a vaginal examination and repositioned the patient. She noted that the fetal heart-rate monitor was not working correctly, and called for an emergency cesarean delivery. The baby was born 42 minutes after the fetal heart rate initially dropped.
The child received a diagnosis of spastic-quadriplegia cerebral palsy (CP). She requires a wheelchair and has severe speech deficits and developmental delays.
PARENT’S CLAIM Cesarean delivery was not performed in a timely manner; the delivery delay was responsible for the injury that caused CP. The ObGyn was negligent in not responding to the initial emergency call. The nurses should have summoned the ObGyn earlier.
DEFENDANTS’ DEFENSE The hospital argued that the nurses followed proper protocol. Furthermore, the hospital noted that the ObGyn did not respond to the first call, and did not request a cesarean delivery for 17 minutes.
The ObGyn claimed that she made the decision to perform cesarean delivery within 5 minutes of her arrival, but it took another 15 minutes to gather the surgical team.
VERDICT A $32,882,860 Pennsylvania verdict was returned against the hospital. The ObGyn was vindicated.
DIFFICULT DELIVERY: ZAVANELLI MANEUVER
At 38 5/7 weeks’ gestation, a woman went to the hospital for induction of labor. Twenty-four hours later, she began to push. After an hour of pushing, the mother was exhausted and had a low-grade fever, and the fetal heart rate was slowing. Her ObGyn, Dr. A, attempted vacuum extraction and performed a midline episiotomy. Shoulder dystocia was encountered and maneuvers were used, but without success. Another ObGyn, Dr. B, arrived to assist and also attempted the maneuvers.
The physicians agreed to try the Zavanelli maneuver, which involves pushing the baby’s head back inside the vagina and performing a cesarean delivery.
The baby was sent to the neonatal intensive care unit, where her breathing quickly normalized without supplemental oxygen. The child has a brachial plexus injury.
PARENTS’ CLAIM Dr. A should have performed an earlier cesarean delivery. Excessive traction was used when shoulder dystocia maneuvers were attempted.
PHYSICIANS’ DEFENSE The ObGyns’ actions saved the baby’s life and prevented serious injury to both mother and baby.
VERDICT An Alabama defense verdict was returned.
Related article:
You are the second responder to a shoulder dystocia emergency. What do you do first? Robert L. Barbieri, MD (Editorial; May 2013)
PLACENTA PREVIA FOUND EARLY, BUT FETUS DIES
A woman's first pregnancy was complicated by complete placenta previa. A cesarean delivery was scheduled at 36 weeks’ gestation. However, before that date, the mother developed vaginal bleeding and was taken to the ED. The covering ObGyn was notified of the mother’s arrival within 15 minutes, but did not come to the hospital for 2.5 hours. After examining her, the ObGyn ordered US evaluation and transferred the mother to the obstetric floor. Nursing notes indicate that the fetal heart rate was 120 bpm at that time.
There are no notes from the ObGyn between 5:30 am and mid-afternoon. There is no record of the fetal heart rate when the mother was taken for US in the afternoon, which revealed fetal demise and a large extraovular hematoma. A cesarean delivery was performed. It was determined that the fetus died from placental abruption.
PARENTS’ CLAIM The mother was not adequately evaluated and monitored, which led to fetal demise. Delivery could have proceeded while the fetus was still alive.
PHYSICIAN’S DEFENSE The case was settled during the trial.
VERDICT A $495,000 Massachusetts settlement was reached.
Related articles:
• What is the optimal time to deliver a woman who has placenta previa? John T. Repke, MD (Examining the Evidence; April 2011)
• Act fast when confronted by a coagulopathy postpartum. Robert L. Barbieri, MD (Editorial; March 2012)
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
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Blue towel left in abdomen: $7.2M verdict
When a 61-year-old woman underwent laparoscopic hysterectomy, her gynecologist, Dr. A, was assisted by another gynecologist (Dr. B), a nurse, and a technician. When Dr. A noted that the uterine artery had been injured, he converted to an open procedure, retracted the bowel, repaired the artery, and completed the operation.
Postdischarge, the patient was febrile and developed abdominal pain and an odorous vaginal discharge. A month later, exploratory surgery revealed a retained blue towel that had been used for bowel retraction. The patient required open healing of the surgical wound and a temporary colostomy. She developed an incisional hernia after colostomy reversal, and hernia repair required resection of a small portion of the bowel.
PATIENT’S CLAIM It was negligent to use a blue towel to retract the bowel. The towel should have been removed from her abdomen before closure.
DEFENDANTS’ DEFENSE The technician claimed that she did not provide the towel, did not see the towel used, and that she was not told that the towel had to be tracked. She noted that its color indicated that it lacked a radiopaque tag, and that hospital policy forbade use of untagged towels in an open wound.
Dr. A claimed that he specifically requested a blue towel because it was absorbent, that the technician provided the towel, and that the towel’s use prevented the patient from bleeding to death.
VERDICT A $7.2 million New York verdict was returned against both gynecologists and the hospital as the technician’s employer.
MISCARRIAGE AFTER D&C
A few days after a woman thought she miscarried, her family practi-tioner (FP) performed a dilation and curettage (D&C).
The patient was at work 12 days later when she expelled a fully formed 14-week fetus into a toilet. She was taken to the emergency department (ED), where the cord was cut. Later that day, she passed placental tissue; a repeat D&C was performed the next day.
PATIENT'S CLAIM The FP did not properly perform the first D&C. Although the pathology report was available to the FP prior to the patient’s postoperative visit, the FP failed to inform the patient that no fetal parts had been extracted.
PHYSICIAN’S DEFENSE Because the FP thought that the fetus had been passed prior to the D&C, she believed the pathology report was appropriate.
The patient had been informed of the possibility of retained products of conception after the D&C. The FP had ordered a blood pregnancy test that would have revealed the presence of retained products of conception, but the patient did not have the test. The patient did not contact the FP to report symptoms that felt like labor pains on the day that she passed the fetus.
VERDICT A bench trial resulted in a $51,000 California verdict.
PREGNANT WOMAN COMPLAINS OF LEG PAIN; DIES OF DVT
A 23-year-old woman went to the ED with pain and swelling in her lower left leg and calf. The symptoms were reported to her ObGyn, who examined and then discharged her within a few hours, with instructions to come for her regularly scheduled prenatal visit.
The patient died 2 weeks later. The cause of death was determined to be a pulmonary embolus from a thrombus of the left popliteal vein.
ESTATE’S CLAIM The ObGyn was negligent in failing to test the patient for thrombosis in her left leg when she was in the ED or several days later at the office, when she continued to report leg pain.
PHYSICIAN’S DEFENSE The patient did not have signs of thrombosis at the ED or at the subsequent office visit. The pathologist reported that the clot that caused the embolus appeared fresh. The ObGyn surmised that it had formed after the patient’s last appointment.
VERDICT A Texas defense verdict was returned.
Mother took topiramate; child born with cleft lip and palate: $3M verdict
When a woman learned she was pregnant in December 2007, she was taking topiramate (Topamax) to treat migraine headaches. She discussed tapering off but not discontinuing topiramate usage with her neurologist. The patient’s ObGyn told her that topiramate was safe to take during pregnancy. The child was born with a cleft lip and palate.
PARENTS’ CLAIM Janssen Pharmaceuticals, manufacturer of Topamax, failed to provide adequate warnings about the potential risks associated with Topamax until labeling was changed in March 2011. Janssen knew of potential birth defects associated with Topamax use during pregnancy more than a decade before the labeling change; Janssen’s associate director of regulatory affairs had testified in an earlier hearing that there was knowledge of related birth defects as early as 1996.
DEFENDANTS’ DEFENSE There is uncertainty as to whether exposure to Topamax during pregnancy causes birth defects. The neurologist had warned the patient of possible risks associated with taking Topamax during pregnancy, but the patient had refused to discontinue the drug.
VERDICT A $3 million Pennsylvania verdict was returned.
Related articles:
• Is it time to rethink the use of oral contraceptives in premenopausal women with migraine? Anne H. Calhoun, MD (Audiocast; October 2013)
• How to choose a contraceptive for a patient who has headaches. Kristina M. Tocce, MD; Stephanie B. Teal, MD, MPH (February 2011)
• The gynecologist’s role in managing menstrual migraine. Anne H. Calhoun, MD (April 2010)
WAS MOTHER’S HISTORY OF INCOMPETENT CERVIX IGNORED?
Early in her second pregnancy, a woman told her ObGyn that she had previously miscarried due to an incompetent cervix.
At 24 weeks’ gestation, the patient was admitted to the hospital with back and pelvic pain and vaginal bleeding. Shortly after admission, the ObGyn performed a vaginal examination and ordered ultrasonography (US), which showed that the fetus was in the transverse position and the membranes were bulging.
The ObGyn performed an emergency cesarean delivery, but the premature infant died within 2 hours.
PARENTS’ CLAIM The ObGyn should have performed a cervical cerclage because of the mother’s history of an incompetent cervix. The mother should have been placed on bed rest and monitored every 2 weeks for cervical dilation.
PHYSICIAN’S DEFENSE The patient underwent regular prenatal evaluations for an incompetent cervix, and the findings were always normal.
VERDICT A Florida defense verdict was returned.
Related article:
A stepwise approach to cervical cerclage. Katrin Karl, MD; Michael Katz, MD (Surgical Technique; June 2012)
ObGyn unresponsive to patient’s postsurgical phone calls
In 2009, a 50-year-old woman reported occasional right lower quadrant pain to her ObGyn. US results were normal. The menopausal patient’s history included three cesarean deliveries, a total abdominal hysterectomy, and a laparoscopic ovarian cystectomy.
When the patient saw her ObGyn in December 2010, she reported intermittent, progressive right lower quadrant pain that radiated down her right leg. She also reported urine loss with coughing or sneezing, and slight pain on intercourse. The ObGyn prescribed oxybutynin chloride (Ditropan) to treat the patient’s incontinence.
Three weeks later, the patient reported bilateral lower quadrant pain to her ObGyn, with minor improvement in incontinence.
The ObGyn performed bilateral salpingo-oophorectomy (BSO) in January 2011. Surgery took 3.5 hours due to extensive adhesiolysis.
After discharge, the patient felt ill and vomited. She attempted to reach the ObGyn by phone several times. That evening, the ObGyn prescribed a suppository to treat nausea and vomiting.
The patient went to the ED later that night and was found to have a perforated colon. Emergency surgery to repair the injury included creation of a colostomy, which was repaired 20 months later.
PATIENT’S CLAIM A proper workup of her symptoms was not performed; BSO was unnecessary. The ObGyn was negligent for failing to respond in a timely manner to her post-discharge phone calls, and did not properly evaluate her postoperative symptoms.
PHYSICIAN’S DEFENSE BSO was warranted. Colon injury is a known complication of the procedure.
VERDICT A $716,976 California verdict was returned, but was reduced to $591,967 under the state cap.
Who delayed delivery? $32.8M verdict for child with CP
An 18-year-old woman at 38 weeks’ gestation went to the hospital in labor. After 3.5 hours, the fetal heart rate dropped to 60 bpm. A nurse repositioned the patient, administered oxygen, and increased intravenous fluids. When the nurse rang the emergency call bell, a second nurse responded. Eighteen minutes after the fetal heart rate first dropped, a nurse rang the call bell again and the on-call ObGyn appeared.
The ObGyn performed a vaginal examination and repositioned the patient. She noted that the fetal heart-rate monitor was not working correctly, and called for an emergency cesarean delivery. The baby was born 42 minutes after the fetal heart rate initially dropped.
The child received a diagnosis of spastic-quadriplegia cerebral palsy (CP). She requires a wheelchair and has severe speech deficits and developmental delays.
PARENT’S CLAIM Cesarean delivery was not performed in a timely manner; the delivery delay was responsible for the injury that caused CP. The ObGyn was negligent in not responding to the initial emergency call. The nurses should have summoned the ObGyn earlier.
DEFENDANTS’ DEFENSE The hospital argued that the nurses followed proper protocol. Furthermore, the hospital noted that the ObGyn did not respond to the first call, and did not request a cesarean delivery for 17 minutes.
The ObGyn claimed that she made the decision to perform cesarean delivery within 5 minutes of her arrival, but it took another 15 minutes to gather the surgical team.
VERDICT A $32,882,860 Pennsylvania verdict was returned against the hospital. The ObGyn was vindicated.
DIFFICULT DELIVERY: ZAVANELLI MANEUVER
At 38 5/7 weeks’ gestation, a woman went to the hospital for induction of labor. Twenty-four hours later, she began to push. After an hour of pushing, the mother was exhausted and had a low-grade fever, and the fetal heart rate was slowing. Her ObGyn, Dr. A, attempted vacuum extraction and performed a midline episiotomy. Shoulder dystocia was encountered and maneuvers were used, but without success. Another ObGyn, Dr. B, arrived to assist and also attempted the maneuvers.
The physicians agreed to try the Zavanelli maneuver, which involves pushing the baby’s head back inside the vagina and performing a cesarean delivery.
The baby was sent to the neonatal intensive care unit, where her breathing quickly normalized without supplemental oxygen. The child has a brachial plexus injury.
PARENTS’ CLAIM Dr. A should have performed an earlier cesarean delivery. Excessive traction was used when shoulder dystocia maneuvers were attempted.
PHYSICIANS’ DEFENSE The ObGyns’ actions saved the baby’s life and prevented serious injury to both mother and baby.
VERDICT An Alabama defense verdict was returned.
Related article:
You are the second responder to a shoulder dystocia emergency. What do you do first? Robert L. Barbieri, MD (Editorial; May 2013)
PLACENTA PREVIA FOUND EARLY, BUT FETUS DIES
A woman's first pregnancy was complicated by complete placenta previa. A cesarean delivery was scheduled at 36 weeks’ gestation. However, before that date, the mother developed vaginal bleeding and was taken to the ED. The covering ObGyn was notified of the mother’s arrival within 15 minutes, but did not come to the hospital for 2.5 hours. After examining her, the ObGyn ordered US evaluation and transferred the mother to the obstetric floor. Nursing notes indicate that the fetal heart rate was 120 bpm at that time.
There are no notes from the ObGyn between 5:30 am and mid-afternoon. There is no record of the fetal heart rate when the mother was taken for US in the afternoon, which revealed fetal demise and a large extraovular hematoma. A cesarean delivery was performed. It was determined that the fetus died from placental abruption.
PARENTS’ CLAIM The mother was not adequately evaluated and monitored, which led to fetal demise. Delivery could have proceeded while the fetus was still alive.
PHYSICIAN’S DEFENSE The case was settled during the trial.
VERDICT A $495,000 Massachusetts settlement was reached.
Related articles:
• What is the optimal time to deliver a woman who has placenta previa? John T. Repke, MD (Examining the Evidence; April 2011)
• Act fast when confronted by a coagulopathy postpartum. Robert L. Barbieri, MD (Editorial; March 2012)
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
TELL US WHAT YOU THINK! Drop us a line and let us know what you think about this or other current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected] Please include your name, city and state. Stay in touch! Your feedback is important to us!
Blue towel left in abdomen: $7.2M verdict
When a 61-year-old woman underwent laparoscopic hysterectomy, her gynecologist, Dr. A, was assisted by another gynecologist (Dr. B), a nurse, and a technician. When Dr. A noted that the uterine artery had been injured, he converted to an open procedure, retracted the bowel, repaired the artery, and completed the operation.
Postdischarge, the patient was febrile and developed abdominal pain and an odorous vaginal discharge. A month later, exploratory surgery revealed a retained blue towel that had been used for bowel retraction. The patient required open healing of the surgical wound and a temporary colostomy. She developed an incisional hernia after colostomy reversal, and hernia repair required resection of a small portion of the bowel.
PATIENT’S CLAIM It was negligent to use a blue towel to retract the bowel. The towel should have been removed from her abdomen before closure.
DEFENDANTS’ DEFENSE The technician claimed that she did not provide the towel, did not see the towel used, and that she was not told that the towel had to be tracked. She noted that its color indicated that it lacked a radiopaque tag, and that hospital policy forbade use of untagged towels in an open wound.
Dr. A claimed that he specifically requested a blue towel because it was absorbent, that the technician provided the towel, and that the towel’s use prevented the patient from bleeding to death.
VERDICT A $7.2 million New York verdict was returned against both gynecologists and the hospital as the technician’s employer.
MISCARRIAGE AFTER D&C
A few days after a woman thought she miscarried, her family practi-tioner (FP) performed a dilation and curettage (D&C).
The patient was at work 12 days later when she expelled a fully formed 14-week fetus into a toilet. She was taken to the emergency department (ED), where the cord was cut. Later that day, she passed placental tissue; a repeat D&C was performed the next day.
PATIENT'S CLAIM The FP did not properly perform the first D&C. Although the pathology report was available to the FP prior to the patient’s postoperative visit, the FP failed to inform the patient that no fetal parts had been extracted.
PHYSICIAN’S DEFENSE Because the FP thought that the fetus had been passed prior to the D&C, she believed the pathology report was appropriate.
The patient had been informed of the possibility of retained products of conception after the D&C. The FP had ordered a blood pregnancy test that would have revealed the presence of retained products of conception, but the patient did not have the test. The patient did not contact the FP to report symptoms that felt like labor pains on the day that she passed the fetus.
VERDICT A bench trial resulted in a $51,000 California verdict.
PREGNANT WOMAN COMPLAINS OF LEG PAIN; DIES OF DVT
A 23-year-old woman went to the ED with pain and swelling in her lower left leg and calf. The symptoms were reported to her ObGyn, who examined and then discharged her within a few hours, with instructions to come for her regularly scheduled prenatal visit.
The patient died 2 weeks later. The cause of death was determined to be a pulmonary embolus from a thrombus of the left popliteal vein.
ESTATE’S CLAIM The ObGyn was negligent in failing to test the patient for thrombosis in her left leg when she was in the ED or several days later at the office, when she continued to report leg pain.
PHYSICIAN’S DEFENSE The patient did not have signs of thrombosis at the ED or at the subsequent office visit. The pathologist reported that the clot that caused the embolus appeared fresh. The ObGyn surmised that it had formed after the patient’s last appointment.
VERDICT A Texas defense verdict was returned.
Mother took topiramate; child born with cleft lip and palate: $3M verdict
When a woman learned she was pregnant in December 2007, she was taking topiramate (Topamax) to treat migraine headaches. She discussed tapering off but not discontinuing topiramate usage with her neurologist. The patient’s ObGyn told her that topiramate was safe to take during pregnancy. The child was born with a cleft lip and palate.
PARENTS’ CLAIM Janssen Pharmaceuticals, manufacturer of Topamax, failed to provide adequate warnings about the potential risks associated with Topamax until labeling was changed in March 2011. Janssen knew of potential birth defects associated with Topamax use during pregnancy more than a decade before the labeling change; Janssen’s associate director of regulatory affairs had testified in an earlier hearing that there was knowledge of related birth defects as early as 1996.
DEFENDANTS’ DEFENSE There is uncertainty as to whether exposure to Topamax during pregnancy causes birth defects. The neurologist had warned the patient of possible risks associated with taking Topamax during pregnancy, but the patient had refused to discontinue the drug.
VERDICT A $3 million Pennsylvania verdict was returned.
Related articles:
• Is it time to rethink the use of oral contraceptives in premenopausal women with migraine? Anne H. Calhoun, MD (Audiocast; October 2013)
• How to choose a contraceptive for a patient who has headaches. Kristina M. Tocce, MD; Stephanie B. Teal, MD, MPH (February 2011)
• The gynecologist’s role in managing menstrual migraine. Anne H. Calhoun, MD (April 2010)
WAS MOTHER’S HISTORY OF INCOMPETENT CERVIX IGNORED?
Early in her second pregnancy, a woman told her ObGyn that she had previously miscarried due to an incompetent cervix.
At 24 weeks’ gestation, the patient was admitted to the hospital with back and pelvic pain and vaginal bleeding. Shortly after admission, the ObGyn performed a vaginal examination and ordered ultrasonography (US), which showed that the fetus was in the transverse position and the membranes were bulging.
The ObGyn performed an emergency cesarean delivery, but the premature infant died within 2 hours.
PARENTS’ CLAIM The ObGyn should have performed a cervical cerclage because of the mother’s history of an incompetent cervix. The mother should have been placed on bed rest and monitored every 2 weeks for cervical dilation.
PHYSICIAN’S DEFENSE The patient underwent regular prenatal evaluations for an incompetent cervix, and the findings were always normal.
VERDICT A Florida defense verdict was returned.
Related article:
A stepwise approach to cervical cerclage. Katrin Karl, MD; Michael Katz, MD (Surgical Technique; June 2012)
ObGyn unresponsive to patient’s postsurgical phone calls
In 2009, a 50-year-old woman reported occasional right lower quadrant pain to her ObGyn. US results were normal. The menopausal patient’s history included three cesarean deliveries, a total abdominal hysterectomy, and a laparoscopic ovarian cystectomy.
When the patient saw her ObGyn in December 2010, she reported intermittent, progressive right lower quadrant pain that radiated down her right leg. She also reported urine loss with coughing or sneezing, and slight pain on intercourse. The ObGyn prescribed oxybutynin chloride (Ditropan) to treat the patient’s incontinence.
Three weeks later, the patient reported bilateral lower quadrant pain to her ObGyn, with minor improvement in incontinence.
The ObGyn performed bilateral salpingo-oophorectomy (BSO) in January 2011. Surgery took 3.5 hours due to extensive adhesiolysis.
After discharge, the patient felt ill and vomited. She attempted to reach the ObGyn by phone several times. That evening, the ObGyn prescribed a suppository to treat nausea and vomiting.
The patient went to the ED later that night and was found to have a perforated colon. Emergency surgery to repair the injury included creation of a colostomy, which was repaired 20 months later.
PATIENT’S CLAIM A proper workup of her symptoms was not performed; BSO was unnecessary. The ObGyn was negligent for failing to respond in a timely manner to her post-discharge phone calls, and did not properly evaluate her postoperative symptoms.
PHYSICIAN’S DEFENSE BSO was warranted. Colon injury is a known complication of the procedure.
VERDICT A $716,976 California verdict was returned, but was reduced to $591,967 under the state cap.
Who delayed delivery? $32.8M verdict for child with CP
An 18-year-old woman at 38 weeks’ gestation went to the hospital in labor. After 3.5 hours, the fetal heart rate dropped to 60 bpm. A nurse repositioned the patient, administered oxygen, and increased intravenous fluids. When the nurse rang the emergency call bell, a second nurse responded. Eighteen minutes after the fetal heart rate first dropped, a nurse rang the call bell again and the on-call ObGyn appeared.
The ObGyn performed a vaginal examination and repositioned the patient. She noted that the fetal heart-rate monitor was not working correctly, and called for an emergency cesarean delivery. The baby was born 42 minutes after the fetal heart rate initially dropped.
The child received a diagnosis of spastic-quadriplegia cerebral palsy (CP). She requires a wheelchair and has severe speech deficits and developmental delays.
PARENT’S CLAIM Cesarean delivery was not performed in a timely manner; the delivery delay was responsible for the injury that caused CP. The ObGyn was negligent in not responding to the initial emergency call. The nurses should have summoned the ObGyn earlier.
DEFENDANTS’ DEFENSE The hospital argued that the nurses followed proper protocol. Furthermore, the hospital noted that the ObGyn did not respond to the first call, and did not request a cesarean delivery for 17 minutes.
The ObGyn claimed that she made the decision to perform cesarean delivery within 5 minutes of her arrival, but it took another 15 minutes to gather the surgical team.
VERDICT A $32,882,860 Pennsylvania verdict was returned against the hospital. The ObGyn was vindicated.
DIFFICULT DELIVERY: ZAVANELLI MANEUVER
At 38 5/7 weeks’ gestation, a woman went to the hospital for induction of labor. Twenty-four hours later, she began to push. After an hour of pushing, the mother was exhausted and had a low-grade fever, and the fetal heart rate was slowing. Her ObGyn, Dr. A, attempted vacuum extraction and performed a midline episiotomy. Shoulder dystocia was encountered and maneuvers were used, but without success. Another ObGyn, Dr. B, arrived to assist and also attempted the maneuvers.
The physicians agreed to try the Zavanelli maneuver, which involves pushing the baby’s head back inside the vagina and performing a cesarean delivery.
The baby was sent to the neonatal intensive care unit, where her breathing quickly normalized without supplemental oxygen. The child has a brachial plexus injury.
PARENTS’ CLAIM Dr. A should have performed an earlier cesarean delivery. Excessive traction was used when shoulder dystocia maneuvers were attempted.
PHYSICIANS’ DEFENSE The ObGyns’ actions saved the baby’s life and prevented serious injury to both mother and baby.
VERDICT An Alabama defense verdict was returned.
Related article:
You are the second responder to a shoulder dystocia emergency. What do you do first? Robert L. Barbieri, MD (Editorial; May 2013)
PLACENTA PREVIA FOUND EARLY, BUT FETUS DIES
A woman's first pregnancy was complicated by complete placenta previa. A cesarean delivery was scheduled at 36 weeks’ gestation. However, before that date, the mother developed vaginal bleeding and was taken to the ED. The covering ObGyn was notified of the mother’s arrival within 15 minutes, but did not come to the hospital for 2.5 hours. After examining her, the ObGyn ordered US evaluation and transferred the mother to the obstetric floor. Nursing notes indicate that the fetal heart rate was 120 bpm at that time.
There are no notes from the ObGyn between 5:30 am and mid-afternoon. There is no record of the fetal heart rate when the mother was taken for US in the afternoon, which revealed fetal demise and a large extraovular hematoma. A cesarean delivery was performed. It was determined that the fetus died from placental abruption.
PARENTS’ CLAIM The mother was not adequately evaluated and monitored, which led to fetal demise. Delivery could have proceeded while the fetus was still alive.
PHYSICIAN’S DEFENSE The case was settled during the trial.
VERDICT A $495,000 Massachusetts settlement was reached.
Related articles:
• What is the optimal time to deliver a woman who has placenta previa? John T. Repke, MD (Examining the Evidence; April 2011)
• Act fast when confronted by a coagulopathy postpartum. Robert L. Barbieri, MD (Editorial; March 2012)
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
TELL US WHAT YOU THINK! Drop us a line and let us know what you think about this or other current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected] Please include your name, city and state. Stay in touch! Your feedback is important to us!
Woman loses both legs after salpingectomy: $64.3M award
Woman loses both legs after salpingectomy: $64.3M award
Due to an ectopic pregnancy, a 29-year-old woman underwent laparoscopic salpingectomy in October 2009. A resident supervised by Dr. A (gynecologist) performed the surgery. Although the patient reported abdominal pain and was febrile, Dr. B (gynecologist) discharged her on postsurgical day 2.
The next day, she returned to the emergency department (ED) with abdominal swelling and pain. Dr. C (ED physician), Dr. D (gynecologist), and Dr. E (general surgeon) examined her. Dr. D began conservative treatment for bowel obstruction. Two days later she was in septic shock. Dr. E repaired a 5-mm injury to the sigmoid colon and created a colostomy. The patient was placed in a medically induced coma for 3 weeks. She experienced cardiac arrest 3 times during her 73-day ICU stay. She underwent skin grafts, and suffered hearing loss as a result of antibiotic treatment. Due to gangrene, both legs were amputated below the knee.
At the trial’s conclusion in January 2014, the colostomy had not been reversed. She has difficulty caring for her daughter and has not worked since the initial operation.
PATIENT’S CLAIM The resident, who injured the colon and did not detect the injury during surgery, was improperly supervised by Dr. A. Hospital staff did not communicate the patient’s problem reports to the physicians. Dr. B should not have discharged her after surgery; based on her reported symptoms, additional testing was warranted. Drs. C, D, and E did not react to the patient’s pain reports in a timely manner, nor treat the resulting sepsis aggressively enough, leading to gangrene.
DEFENDANTS’ DEFENSE The patient’s colon injury was diagnosed and treated in a timely manner, but her condition deteriorated rapidly. The physicians acted responsibly based on the available information; a computed tomography scan did not show the colon injury. The injury likely occurred after the procedure due to an underlying bowel condition and is a known risk of the procedure. The colostomy can be reversed. Their efforts saved her life.
VERDICT The patient and Dr. E negotiated a $2.3 million settlement. A $62 million New York verdict was returned. The jury found the hospital 40% liable; Dr. A 30% liable; Dr. B 20% liable; and Dr. D 10% liable. Claims were dropped against the resident and Dr. C.
Related article: Oophorectomy or salpingectomy—which makes more sense? William H. Parker, MD (March 2014)
PARENTS REQUESTED EARLIER CESAREAN: CHILD HAS CP
A woman was in labor for 2 full days before her ObGyn performed a cesarean delivery. The child was born with abnormal Apgar scores and had seizures. Imaging studies revealed brain damage. She received a diagnosis of cerebral palsy.
PARENTS’ CLAIM The parents first requested cesarean delivery early on the second day, but the ObGyn allowed labor to progress. When the fetal heart-rate monitor showed signs of fetal distress 3 hours later, the parents made a second request; the ObGyn continued with vaginal delivery. The child was ultimately born by cesarean delivery. Her brain damage was caused by lack of oxygen from failure to perform an earlier cesarean delivery.
DEFENDANTS’ DEFENSE The case was settled during the trial.
VERDICT A $4.25 million Massachusetts settlement was reached.
BLADDER INJURED DURING CESAREAN DELIVERY
A 33-year-old woman gave birth via cesarean delivery performed by her ObGyn. During the procedure, the patient’s bladder was lacerated and the injury was immediately repaired. The patient reports occasional urinary incontinence and pain.
PATIENT’S CLAIM The ObGyn should have anticipated that the bladder would be shifted because of the patient’s previous cesarean delivery.
PHYSICIAN’S DEFENSE The injury is a known risk of the procedure. The patient had developed adhesions that caused the bladder to become displaced. She does not suffer permanent residual effects from the injury.
VERDICT A $125,000 New York verdict was returned.
Related article: 10 practical, evidence-based recommendations for improving maternal outcomes of cesarean delivery. Baha M. Sibai (March 2012)
PARENTS REQUESTED SPECIFIC GENETIC TESTING, BUT CHILD IS BORN WITH RARE CHROMOSOMAL CONDITION: $50M VERDICT
Parents sought prenatal genetic testing to determine if their fetus had a specific genetic condition because the father carries a rare chromosomal abnormality called an unbalanced chromosome translocation. This defect can only be identified if the laboratory is told precisely where to look for the specific translocation; it is not detected on routine prenatal genetic testing. After testing, the parents were told that the fetus did not have the chromosomal abnormality.
The child was born with the condition for which testing was sought, resulting in severe physical and cognitive impairments and multiple physical abnormalities. He will require 24-hour care for life.
PARENTS’ CLAIM Testing failed to identify the condition; the couple had decided to terminate the pregnancy if the child was affected. Due to budget cuts in the maternal-fetal medicine clinic, the medical center borrowed a genetic counselor from another hospital one day a week. The parents told the genetic counselor of the family’s history of the defect and explained that the laboratory’s procedures require the referring center to obtain and share the necessary detailed information with the lab. The lab was apparently notified that the couple had a family history of the defect, but the genetic counselor did not transmit specific information to the lab, and lab personnel did not appropriately follow-up.
DEFENDANTS’ DEFENSE The medical center blamed the laboratory: the lab’s standard procedures state that the lab should call the referring center to obtain the necessary detailed information if it was not provided; the lab employee who handled the specimen did not do so. The lab claimed that the genetic counselor did not transmit the specific information to the lab.
The laboratory disputed the child’s need for 24/7 care, maintaining that he could live in a group home with only occasional nursing care.
VERDICT A $50 million Washington verdict was returned against the medical center and laboratory; each defendant will pay $25 million.
Related article: Noninvasive prenatal testing: Where we are and where we’re going. Lee P. Shulman, MD (Commentary; May 2014)
NECROTIZING FASCIITIS AFTER SURGERY
A 57-year-old woman underwent surgery to repair vaginal vault prolapse, rectocele, and enterocele, performed by her gynecologist. Several days after discharge, the patient returned to the hospital with an infection in her leg that had evolved into necrotizing fasciitis. She underwent five fasciotomies and was hospitalized for 3 weeks.
PATIENT’S CLAIM The gynecologist should have administered prophylactic antibiotics before, during, and after surgery. The patient has massive scarring of her leg.
PHYSICIAN’S DEFENSE The infection was not a result of failing to administer antibiotics. The patient failed to seek timely treatment of symptoms that developed after surgery.
VERDICT A $400,000 New York verdict was returned but reduced because the jury found the patient 49% at fault.
OXYTOCIN BLAMED FOR CHILD’S CP
A mother had bariatric surgery 12 months before becoming pregnant, and she smoked during pregnancy. She developed placental insufficiency and labor was induced shortly after she reached 37 weeks’ gestation.
During delivery, the mother was given oxytocin to increase the frequency and strength of contractions. Nurses repeatedly stopped the oxytocin in response to decelerations in the fetal heart rate, but physicians ordered the oxytocin resumed, even after fetal heart-rate monitoring showed fetal distress.
Three days after birth, the child was transferred to another hospital, and was found to have cerebral palsy and other injuries. At age 5, the child is nonverbal, cannot walk, and requires a feeding tube.
PARENTS’ CLAIM Oxytocin should have been stopped and a cesarean delivery performed when fetal distress was first noted.
DEFENDANTS’ DEFENSE There was no need for cesarean delivery. Apgar scores, blood gases, and fetal presentation indicated that the injury occurred prior to labor.
VERDICT A $6 million Texas settlement was reached during the trial.
Related article: Q: Following cesarean delivery, what is the optimal oxytocin infusion duration to prevent postpartum bleeding? Robert L. Barbieri, MD (Editorial; April 2014)
MOTHER DISCHARGED DESPITE SEVERE ABDOMINAL PAIN
A woman had prenatal care at different locations. Her history included two cesarean deliveries.
Reporting severe abdominal pain, she was taken from a homeless shelter to an ED by ambulance. The mother was uncertain of the fetus’ gestational age; a 4th-year obstetric resident determined by physical examination that the pregnancy was at 36.5 weeks. The resident discussed the case with the attending ObGyn, who said to discharge the mother if her pain was gone. After 11 hours, the mother was returned to the shelter.
The mother returned to the ED 12 hours later. Thirty-five minutes after fetal distress was identified, an emergency cesarean delivery was performed. At birth, the child was found to be at 38 to 39 weeks’ gestation. He received a diagnosis of severe hypoxic ischemic encephalopathy and was transferred to a children’s hospital for brain cooling.
The child lives in a long-term care facility and is dependent on a ventilator and gastronomy tube.
PARENT’S CLAIM The mother should not have been discharged after the first visit. A cesarean delivery should have been performed at that time. The attending ObGyn never saw the mother.
DEFENDANTS’ DEFENSE The mother should have given her correct due date, which was in her prenatal records based on previous ultrasonograpy. The first discharge was proper, as the pain had improved. The homeless shelter should have called an ambulance earlier for the second admission.
VERDICT A $7.5 million California settlement was reached, plus payment of medical expenses exceeding $300,000.
Timing of child’s injury disputed
Vaginal birth after cesarean (VBAC) had been planned. After reporting to her ObGyn that she was in labor, a mother went to the ED.
During the next few hours, hospital staff called the ObGyn twice to report that fetal monitor strips indicated tachycardia. The ObGyn then spoke to the mother by phone and told her that cesarean delivery was necessary but could wait for him to get to the hospital. After the ObGyn arrived, he removed the fetal heart-rate monitor to prepare the mother’s abdomen; cesarean delivery occurred 15 minutes later.
The child has spastic dystonic quadriplegia and requires 24-hour care.
PARENT’S CLAIM The ObGyn should have come to the hospital and performed cesarean delivery when he was first notified that the fetus was tachycardic. The baby suffered an hypoxic ischemic event in the 15-minute period between when the monitor was removed and birth, causing hypoxic ischemic encephalopathy.
PHYSICIAN’S DEFENSE There was no indication of a need for earlier delivery. The brain injury occurred prior to labor and delivery.
VERDICT The hospital settled for a confidential amount before the trial. An Illinois defense verdict was returned for the ObGyn.
Were mammograms properly interpreted?
After reporting a lump in her breast, a 39-year-old woman underwent mammography in 2008 and 2009. Two different radiologists reported their findings as negative for cancer.
In 2010, the patient was found to have breast cancer. She underwent a mastectomy, chemotherapy, and radiation therapy, and was given a 75%–80% chance of 5-year survival.
PATIENT’S CLAIM The ObGyn failed to follow-up on the patient’s reports of a breast lump. The radiologists did not correctly interpret the 2008 and 2009 mammograms. If cancer had been detected earlier, treatment would have been less extreme.
PHYSICIANS’ DEFENSE The ObGyn claimed that he would have felt a lump if it was present. The first radiologist claimed that the 2008 mammography report was correct, noting that the patient’s cancer was a lobular carcinoma that does not always show on mammography or in patients with dense breasts, which this patient has.
VERDICT A directed verdict was granted to the radiologist who interpreted the 2009 mammography, as the results were lost. An Ohio defense verdict was returned for the ObGyn and the other radiologist.
Related article: Does screening mammography save lives? Janelle Yates, Senior Editor (April 2014)
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
TELL US WHAT YOU THINK! Drop us a line and let us know what you think about this or other current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice.
Tell us what you think by emailing us at: [email protected] Please include your name, city and state.
Stay in touch! Your feedback is important to us!
Woman loses both legs after salpingectomy: $64.3M award
Due to an ectopic pregnancy, a 29-year-old woman underwent laparoscopic salpingectomy in October 2009. A resident supervised by Dr. A (gynecologist) performed the surgery. Although the patient reported abdominal pain and was febrile, Dr. B (gynecologist) discharged her on postsurgical day 2.
The next day, she returned to the emergency department (ED) with abdominal swelling and pain. Dr. C (ED physician), Dr. D (gynecologist), and Dr. E (general surgeon) examined her. Dr. D began conservative treatment for bowel obstruction. Two days later she was in septic shock. Dr. E repaired a 5-mm injury to the sigmoid colon and created a colostomy. The patient was placed in a medically induced coma for 3 weeks. She experienced cardiac arrest 3 times during her 73-day ICU stay. She underwent skin grafts, and suffered hearing loss as a result of antibiotic treatment. Due to gangrene, both legs were amputated below the knee.
At the trial’s conclusion in January 2014, the colostomy had not been reversed. She has difficulty caring for her daughter and has not worked since the initial operation.
PATIENT’S CLAIM The resident, who injured the colon and did not detect the injury during surgery, was improperly supervised by Dr. A. Hospital staff did not communicate the patient’s problem reports to the physicians. Dr. B should not have discharged her after surgery; based on her reported symptoms, additional testing was warranted. Drs. C, D, and E did not react to the patient’s pain reports in a timely manner, nor treat the resulting sepsis aggressively enough, leading to gangrene.
DEFENDANTS’ DEFENSE The patient’s colon injury was diagnosed and treated in a timely manner, but her condition deteriorated rapidly. The physicians acted responsibly based on the available information; a computed tomography scan did not show the colon injury. The injury likely occurred after the procedure due to an underlying bowel condition and is a known risk of the procedure. The colostomy can be reversed. Their efforts saved her life.
VERDICT The patient and Dr. E negotiated a $2.3 million settlement. A $62 million New York verdict was returned. The jury found the hospital 40% liable; Dr. A 30% liable; Dr. B 20% liable; and Dr. D 10% liable. Claims were dropped against the resident and Dr. C.
Related article: Oophorectomy or salpingectomy—which makes more sense? William H. Parker, MD (March 2014)
PARENTS REQUESTED EARLIER CESAREAN: CHILD HAS CP
A woman was in labor for 2 full days before her ObGyn performed a cesarean delivery. The child was born with abnormal Apgar scores and had seizures. Imaging studies revealed brain damage. She received a diagnosis of cerebral palsy.
PARENTS’ CLAIM The parents first requested cesarean delivery early on the second day, but the ObGyn allowed labor to progress. When the fetal heart-rate monitor showed signs of fetal distress 3 hours later, the parents made a second request; the ObGyn continued with vaginal delivery. The child was ultimately born by cesarean delivery. Her brain damage was caused by lack of oxygen from failure to perform an earlier cesarean delivery.
DEFENDANTS’ DEFENSE The case was settled during the trial.
VERDICT A $4.25 million Massachusetts settlement was reached.
BLADDER INJURED DURING CESAREAN DELIVERY
A 33-year-old woman gave birth via cesarean delivery performed by her ObGyn. During the procedure, the patient’s bladder was lacerated and the injury was immediately repaired. The patient reports occasional urinary incontinence and pain.
PATIENT’S CLAIM The ObGyn should have anticipated that the bladder would be shifted because of the patient’s previous cesarean delivery.
PHYSICIAN’S DEFENSE The injury is a known risk of the procedure. The patient had developed adhesions that caused the bladder to become displaced. She does not suffer permanent residual effects from the injury.
VERDICT A $125,000 New York verdict was returned.
Related article: 10 practical, evidence-based recommendations for improving maternal outcomes of cesarean delivery. Baha M. Sibai (March 2012)
PARENTS REQUESTED SPECIFIC GENETIC TESTING, BUT CHILD IS BORN WITH RARE CHROMOSOMAL CONDITION: $50M VERDICT
Parents sought prenatal genetic testing to determine if their fetus had a specific genetic condition because the father carries a rare chromosomal abnormality called an unbalanced chromosome translocation. This defect can only be identified if the laboratory is told precisely where to look for the specific translocation; it is not detected on routine prenatal genetic testing. After testing, the parents were told that the fetus did not have the chromosomal abnormality.
The child was born with the condition for which testing was sought, resulting in severe physical and cognitive impairments and multiple physical abnormalities. He will require 24-hour care for life.
PARENTS’ CLAIM Testing failed to identify the condition; the couple had decided to terminate the pregnancy if the child was affected. Due to budget cuts in the maternal-fetal medicine clinic, the medical center borrowed a genetic counselor from another hospital one day a week. The parents told the genetic counselor of the family’s history of the defect and explained that the laboratory’s procedures require the referring center to obtain and share the necessary detailed information with the lab. The lab was apparently notified that the couple had a family history of the defect, but the genetic counselor did not transmit specific information to the lab, and lab personnel did not appropriately follow-up.
DEFENDANTS’ DEFENSE The medical center blamed the laboratory: the lab’s standard procedures state that the lab should call the referring center to obtain the necessary detailed information if it was not provided; the lab employee who handled the specimen did not do so. The lab claimed that the genetic counselor did not transmit the specific information to the lab.
The laboratory disputed the child’s need for 24/7 care, maintaining that he could live in a group home with only occasional nursing care.
VERDICT A $50 million Washington verdict was returned against the medical center and laboratory; each defendant will pay $25 million.
Related article: Noninvasive prenatal testing: Where we are and where we’re going. Lee P. Shulman, MD (Commentary; May 2014)
NECROTIZING FASCIITIS AFTER SURGERY
A 57-year-old woman underwent surgery to repair vaginal vault prolapse, rectocele, and enterocele, performed by her gynecologist. Several days after discharge, the patient returned to the hospital with an infection in her leg that had evolved into necrotizing fasciitis. She underwent five fasciotomies and was hospitalized for 3 weeks.
PATIENT’S CLAIM The gynecologist should have administered prophylactic antibiotics before, during, and after surgery. The patient has massive scarring of her leg.
PHYSICIAN’S DEFENSE The infection was not a result of failing to administer antibiotics. The patient failed to seek timely treatment of symptoms that developed after surgery.
VERDICT A $400,000 New York verdict was returned but reduced because the jury found the patient 49% at fault.
OXYTOCIN BLAMED FOR CHILD’S CP
A mother had bariatric surgery 12 months before becoming pregnant, and she smoked during pregnancy. She developed placental insufficiency and labor was induced shortly after she reached 37 weeks’ gestation.
During delivery, the mother was given oxytocin to increase the frequency and strength of contractions. Nurses repeatedly stopped the oxytocin in response to decelerations in the fetal heart rate, but physicians ordered the oxytocin resumed, even after fetal heart-rate monitoring showed fetal distress.
Three days after birth, the child was transferred to another hospital, and was found to have cerebral palsy and other injuries. At age 5, the child is nonverbal, cannot walk, and requires a feeding tube.
PARENTS’ CLAIM Oxytocin should have been stopped and a cesarean delivery performed when fetal distress was first noted.
DEFENDANTS’ DEFENSE There was no need for cesarean delivery. Apgar scores, blood gases, and fetal presentation indicated that the injury occurred prior to labor.
VERDICT A $6 million Texas settlement was reached during the trial.
Related article: Q: Following cesarean delivery, what is the optimal oxytocin infusion duration to prevent postpartum bleeding? Robert L. Barbieri, MD (Editorial; April 2014)
MOTHER DISCHARGED DESPITE SEVERE ABDOMINAL PAIN
A woman had prenatal care at different locations. Her history included two cesarean deliveries.
Reporting severe abdominal pain, she was taken from a homeless shelter to an ED by ambulance. The mother was uncertain of the fetus’ gestational age; a 4th-year obstetric resident determined by physical examination that the pregnancy was at 36.5 weeks. The resident discussed the case with the attending ObGyn, who said to discharge the mother if her pain was gone. After 11 hours, the mother was returned to the shelter.
The mother returned to the ED 12 hours later. Thirty-five minutes after fetal distress was identified, an emergency cesarean delivery was performed. At birth, the child was found to be at 38 to 39 weeks’ gestation. He received a diagnosis of severe hypoxic ischemic encephalopathy and was transferred to a children’s hospital for brain cooling.
The child lives in a long-term care facility and is dependent on a ventilator and gastronomy tube.
PARENT’S CLAIM The mother should not have been discharged after the first visit. A cesarean delivery should have been performed at that time. The attending ObGyn never saw the mother.
DEFENDANTS’ DEFENSE The mother should have given her correct due date, which was in her prenatal records based on previous ultrasonograpy. The first discharge was proper, as the pain had improved. The homeless shelter should have called an ambulance earlier for the second admission.
VERDICT A $7.5 million California settlement was reached, plus payment of medical expenses exceeding $300,000.
Timing of child’s injury disputed
Vaginal birth after cesarean (VBAC) had been planned. After reporting to her ObGyn that she was in labor, a mother went to the ED.
During the next few hours, hospital staff called the ObGyn twice to report that fetal monitor strips indicated tachycardia. The ObGyn then spoke to the mother by phone and told her that cesarean delivery was necessary but could wait for him to get to the hospital. After the ObGyn arrived, he removed the fetal heart-rate monitor to prepare the mother’s abdomen; cesarean delivery occurred 15 minutes later.
The child has spastic dystonic quadriplegia and requires 24-hour care.
PARENT’S CLAIM The ObGyn should have come to the hospital and performed cesarean delivery when he was first notified that the fetus was tachycardic. The baby suffered an hypoxic ischemic event in the 15-minute period between when the monitor was removed and birth, causing hypoxic ischemic encephalopathy.
PHYSICIAN’S DEFENSE There was no indication of a need for earlier delivery. The brain injury occurred prior to labor and delivery.
VERDICT The hospital settled for a confidential amount before the trial. An Illinois defense verdict was returned for the ObGyn.
Were mammograms properly interpreted?
After reporting a lump in her breast, a 39-year-old woman underwent mammography in 2008 and 2009. Two different radiologists reported their findings as negative for cancer.
In 2010, the patient was found to have breast cancer. She underwent a mastectomy, chemotherapy, and radiation therapy, and was given a 75%–80% chance of 5-year survival.
PATIENT’S CLAIM The ObGyn failed to follow-up on the patient’s reports of a breast lump. The radiologists did not correctly interpret the 2008 and 2009 mammograms. If cancer had been detected earlier, treatment would have been less extreme.
PHYSICIANS’ DEFENSE The ObGyn claimed that he would have felt a lump if it was present. The first radiologist claimed that the 2008 mammography report was correct, noting that the patient’s cancer was a lobular carcinoma that does not always show on mammography or in patients with dense breasts, which this patient has.
VERDICT A directed verdict was granted to the radiologist who interpreted the 2009 mammography, as the results were lost. An Ohio defense verdict was returned for the ObGyn and the other radiologist.
Related article: Does screening mammography save lives? Janelle Yates, Senior Editor (April 2014)
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
TELL US WHAT YOU THINK! Drop us a line and let us know what you think about this or other current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice.
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Woman loses both legs after salpingectomy: $64.3M award
Due to an ectopic pregnancy, a 29-year-old woman underwent laparoscopic salpingectomy in October 2009. A resident supervised by Dr. A (gynecologist) performed the surgery. Although the patient reported abdominal pain and was febrile, Dr. B (gynecologist) discharged her on postsurgical day 2.
The next day, she returned to the emergency department (ED) with abdominal swelling and pain. Dr. C (ED physician), Dr. D (gynecologist), and Dr. E (general surgeon) examined her. Dr. D began conservative treatment for bowel obstruction. Two days later she was in septic shock. Dr. E repaired a 5-mm injury to the sigmoid colon and created a colostomy. The patient was placed in a medically induced coma for 3 weeks. She experienced cardiac arrest 3 times during her 73-day ICU stay. She underwent skin grafts, and suffered hearing loss as a result of antibiotic treatment. Due to gangrene, both legs were amputated below the knee.
At the trial’s conclusion in January 2014, the colostomy had not been reversed. She has difficulty caring for her daughter and has not worked since the initial operation.
PATIENT’S CLAIM The resident, who injured the colon and did not detect the injury during surgery, was improperly supervised by Dr. A. Hospital staff did not communicate the patient’s problem reports to the physicians. Dr. B should not have discharged her after surgery; based on her reported symptoms, additional testing was warranted. Drs. C, D, and E did not react to the patient’s pain reports in a timely manner, nor treat the resulting sepsis aggressively enough, leading to gangrene.
DEFENDANTS’ DEFENSE The patient’s colon injury was diagnosed and treated in a timely manner, but her condition deteriorated rapidly. The physicians acted responsibly based on the available information; a computed tomography scan did not show the colon injury. The injury likely occurred after the procedure due to an underlying bowel condition and is a known risk of the procedure. The colostomy can be reversed. Their efforts saved her life.
VERDICT The patient and Dr. E negotiated a $2.3 million settlement. A $62 million New York verdict was returned. The jury found the hospital 40% liable; Dr. A 30% liable; Dr. B 20% liable; and Dr. D 10% liable. Claims were dropped against the resident and Dr. C.
Related article: Oophorectomy or salpingectomy—which makes more sense? William H. Parker, MD (March 2014)
PARENTS REQUESTED EARLIER CESAREAN: CHILD HAS CP
A woman was in labor for 2 full days before her ObGyn performed a cesarean delivery. The child was born with abnormal Apgar scores and had seizures. Imaging studies revealed brain damage. She received a diagnosis of cerebral palsy.
PARENTS’ CLAIM The parents first requested cesarean delivery early on the second day, but the ObGyn allowed labor to progress. When the fetal heart-rate monitor showed signs of fetal distress 3 hours later, the parents made a second request; the ObGyn continued with vaginal delivery. The child was ultimately born by cesarean delivery. Her brain damage was caused by lack of oxygen from failure to perform an earlier cesarean delivery.
DEFENDANTS’ DEFENSE The case was settled during the trial.
VERDICT A $4.25 million Massachusetts settlement was reached.
BLADDER INJURED DURING CESAREAN DELIVERY
A 33-year-old woman gave birth via cesarean delivery performed by her ObGyn. During the procedure, the patient’s bladder was lacerated and the injury was immediately repaired. The patient reports occasional urinary incontinence and pain.
PATIENT’S CLAIM The ObGyn should have anticipated that the bladder would be shifted because of the patient’s previous cesarean delivery.
PHYSICIAN’S DEFENSE The injury is a known risk of the procedure. The patient had developed adhesions that caused the bladder to become displaced. She does not suffer permanent residual effects from the injury.
VERDICT A $125,000 New York verdict was returned.
Related article: 10 practical, evidence-based recommendations for improving maternal outcomes of cesarean delivery. Baha M. Sibai (March 2012)
PARENTS REQUESTED SPECIFIC GENETIC TESTING, BUT CHILD IS BORN WITH RARE CHROMOSOMAL CONDITION: $50M VERDICT
Parents sought prenatal genetic testing to determine if their fetus had a specific genetic condition because the father carries a rare chromosomal abnormality called an unbalanced chromosome translocation. This defect can only be identified if the laboratory is told precisely where to look for the specific translocation; it is not detected on routine prenatal genetic testing. After testing, the parents were told that the fetus did not have the chromosomal abnormality.
The child was born with the condition for which testing was sought, resulting in severe physical and cognitive impairments and multiple physical abnormalities. He will require 24-hour care for life.
PARENTS’ CLAIM Testing failed to identify the condition; the couple had decided to terminate the pregnancy if the child was affected. Due to budget cuts in the maternal-fetal medicine clinic, the medical center borrowed a genetic counselor from another hospital one day a week. The parents told the genetic counselor of the family’s history of the defect and explained that the laboratory’s procedures require the referring center to obtain and share the necessary detailed information with the lab. The lab was apparently notified that the couple had a family history of the defect, but the genetic counselor did not transmit specific information to the lab, and lab personnel did not appropriately follow-up.
DEFENDANTS’ DEFENSE The medical center blamed the laboratory: the lab’s standard procedures state that the lab should call the referring center to obtain the necessary detailed information if it was not provided; the lab employee who handled the specimen did not do so. The lab claimed that the genetic counselor did not transmit the specific information to the lab.
The laboratory disputed the child’s need for 24/7 care, maintaining that he could live in a group home with only occasional nursing care.
VERDICT A $50 million Washington verdict was returned against the medical center and laboratory; each defendant will pay $25 million.
Related article: Noninvasive prenatal testing: Where we are and where we’re going. Lee P. Shulman, MD (Commentary; May 2014)
NECROTIZING FASCIITIS AFTER SURGERY
A 57-year-old woman underwent surgery to repair vaginal vault prolapse, rectocele, and enterocele, performed by her gynecologist. Several days after discharge, the patient returned to the hospital with an infection in her leg that had evolved into necrotizing fasciitis. She underwent five fasciotomies and was hospitalized for 3 weeks.
PATIENT’S CLAIM The gynecologist should have administered prophylactic antibiotics before, during, and after surgery. The patient has massive scarring of her leg.
PHYSICIAN’S DEFENSE The infection was not a result of failing to administer antibiotics. The patient failed to seek timely treatment of symptoms that developed after surgery.
VERDICT A $400,000 New York verdict was returned but reduced because the jury found the patient 49% at fault.
OXYTOCIN BLAMED FOR CHILD’S CP
A mother had bariatric surgery 12 months before becoming pregnant, and she smoked during pregnancy. She developed placental insufficiency and labor was induced shortly after she reached 37 weeks’ gestation.
During delivery, the mother was given oxytocin to increase the frequency and strength of contractions. Nurses repeatedly stopped the oxytocin in response to decelerations in the fetal heart rate, but physicians ordered the oxytocin resumed, even after fetal heart-rate monitoring showed fetal distress.
Three days after birth, the child was transferred to another hospital, and was found to have cerebral palsy and other injuries. At age 5, the child is nonverbal, cannot walk, and requires a feeding tube.
PARENTS’ CLAIM Oxytocin should have been stopped and a cesarean delivery performed when fetal distress was first noted.
DEFENDANTS’ DEFENSE There was no need for cesarean delivery. Apgar scores, blood gases, and fetal presentation indicated that the injury occurred prior to labor.
VERDICT A $6 million Texas settlement was reached during the trial.
Related article: Q: Following cesarean delivery, what is the optimal oxytocin infusion duration to prevent postpartum bleeding? Robert L. Barbieri, MD (Editorial; April 2014)
MOTHER DISCHARGED DESPITE SEVERE ABDOMINAL PAIN
A woman had prenatal care at different locations. Her history included two cesarean deliveries.
Reporting severe abdominal pain, she was taken from a homeless shelter to an ED by ambulance. The mother was uncertain of the fetus’ gestational age; a 4th-year obstetric resident determined by physical examination that the pregnancy was at 36.5 weeks. The resident discussed the case with the attending ObGyn, who said to discharge the mother if her pain was gone. After 11 hours, the mother was returned to the shelter.
The mother returned to the ED 12 hours later. Thirty-five minutes after fetal distress was identified, an emergency cesarean delivery was performed. At birth, the child was found to be at 38 to 39 weeks’ gestation. He received a diagnosis of severe hypoxic ischemic encephalopathy and was transferred to a children’s hospital for brain cooling.
The child lives in a long-term care facility and is dependent on a ventilator and gastronomy tube.
PARENT’S CLAIM The mother should not have been discharged after the first visit. A cesarean delivery should have been performed at that time. The attending ObGyn never saw the mother.
DEFENDANTS’ DEFENSE The mother should have given her correct due date, which was in her prenatal records based on previous ultrasonograpy. The first discharge was proper, as the pain had improved. The homeless shelter should have called an ambulance earlier for the second admission.
VERDICT A $7.5 million California settlement was reached, plus payment of medical expenses exceeding $300,000.
Timing of child’s injury disputed
Vaginal birth after cesarean (VBAC) had been planned. After reporting to her ObGyn that she was in labor, a mother went to the ED.
During the next few hours, hospital staff called the ObGyn twice to report that fetal monitor strips indicated tachycardia. The ObGyn then spoke to the mother by phone and told her that cesarean delivery was necessary but could wait for him to get to the hospital. After the ObGyn arrived, he removed the fetal heart-rate monitor to prepare the mother’s abdomen; cesarean delivery occurred 15 minutes later.
The child has spastic dystonic quadriplegia and requires 24-hour care.
PARENT’S CLAIM The ObGyn should have come to the hospital and performed cesarean delivery when he was first notified that the fetus was tachycardic. The baby suffered an hypoxic ischemic event in the 15-minute period between when the monitor was removed and birth, causing hypoxic ischemic encephalopathy.
PHYSICIAN’S DEFENSE There was no indication of a need for earlier delivery. The brain injury occurred prior to labor and delivery.
VERDICT The hospital settled for a confidential amount before the trial. An Illinois defense verdict was returned for the ObGyn.
Were mammograms properly interpreted?
After reporting a lump in her breast, a 39-year-old woman underwent mammography in 2008 and 2009. Two different radiologists reported their findings as negative for cancer.
In 2010, the patient was found to have breast cancer. She underwent a mastectomy, chemotherapy, and radiation therapy, and was given a 75%–80% chance of 5-year survival.
PATIENT’S CLAIM The ObGyn failed to follow-up on the patient’s reports of a breast lump. The radiologists did not correctly interpret the 2008 and 2009 mammograms. If cancer had been detected earlier, treatment would have been less extreme.
PHYSICIANS’ DEFENSE The ObGyn claimed that he would have felt a lump if it was present. The first radiologist claimed that the 2008 mammography report was correct, noting that the patient’s cancer was a lobular carcinoma that does not always show on mammography or in patients with dense breasts, which this patient has.
VERDICT A directed verdict was granted to the radiologist who interpreted the 2009 mammography, as the results were lost. An Ohio defense verdict was returned for the ObGyn and the other radiologist.
Related article: Does screening mammography save lives? Janelle Yates, Senior Editor (April 2014)
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
TELL US WHAT YOU THINK! Drop us a line and let us know what you think about this or other current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice.
Tell us what you think by emailing us at: [email protected] Please include your name, city and state.
Stay in touch! Your feedback is important to us!
