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Legal Review & Commentary
Failure to discover that autistic child swallowed foreign object leads to death and $1 million verdict in Illinois
By Jon T. Gatto, Esq., Blake J. Delaney, Esq., Buchanan Ingersoll & Rooney, Tampa, FL
News: An autistic girl with a history of swallowing foreign objects was taken to the emergency department by her mother following repeated episodes of vomiting and constipation. The girl was admitted to the hospital by her pediatrician, and X-rays were ordered. After more than eight hours, a radiologist finally read the films and discovered that the girl had swallowed a small rubber ball. His report, however, was not transmitted to the pediatrician. The girl's condition worsened, and she subsequently coded and died. After the girls' estate sued the hospital and the pediatrician, a jury returned a verdict of $1 million. It assessed the pediatrician with 25% fault and the hospital with 75% fault.
Background: An 8-year-old autistic girl was rushed to the emergency department by her mother after the child had experienced repeated episodes of vomiting since the previous day and had had no bowel movement for two days. The mother informed emergency department personnel that her daughter had swallowed foreign objects in the past but that she had no knowledge of her having done so recently. The child was unable to relay any history herself.
The ED physician noted that the girl was dehydrated, had abdominal pain, and had an elevated white blood cell count. The doctor consulted with the child's pediatrician, who decided to admit the girl for observation. The ED physician ordered abdominal X-rays to rule out a possible foreign body ingestion and bowel obstruction even though he knew there was no radiologist at the hospital to review them. The X-rays were taken, but the ED physician did not review the films himself.
Seven hours later, the girl's pediatrician examined the child and observed her to be in stable condition. He also noted that results were not yet available from the radiology films. An hour and a half later and 8½ hours after the X-rays were taken a radiologist finally arrived at the hospital and read the films. He noted an obstruction in the girl's small bowel, apparently as a result of the girl having swallowed a 1-inch rubber ball. However, either the radiologist's report never made it to the floor, or the nurse failed to call the pediatrician with the results.
The child's condition subsequently worsened. She coded a few hours later and was taken to surgery for an exploratory laparotomy. The ball was not found during the procedure, and the girl died the next morning. During the subsequent autopsy, the ball was discovered in the child's colon, where it had apparently moved from the small bowel.
The girl's estate sued the hospital, the pediatrician, and the pediatrician's practice for negligence. She argued that if the obstruction had been promptly treated, the child would have survived.
The hospital defended the suit by arguing that the ED physician did not need to read the X-rays because the girl had been admitted by her pediatrician. The hospital also contended that its nurses acted properly and that it was the pediatrician who should have reviewed the films. The pediatrician defended the claim by arguing that he does not read X-rays, but instead he relies on a radiology report, which always was relayed to him by nurses. He pointed out that no one had told him of the X-ray results or of any change in the girl's condition. Both defendants then argued that the child would have died in any event.
After a trial, a jury found the pediatrician to be 25% at fault and the hospital to be 75% at fault. Damages were assessed at $1 million.
What this means to you: "This case was doomed for a large jury award just because it involved a child, with the added dimension that the negligence was the immediate cause of the child's death," says Lynn Rosenblatt, CRRN, LHRM, risk manager at HealthSouth Sea Pines Rehabilitation Hospital in Melbourne, FL. "Juries will more likely than not to find for the plaintiff if they strongly believe the defendants breached a standard of care." In this particular case, she finds, it would have been wise for the defendants and their insurance companies to attempt to reach a mediated settlement with the parents rather than expose the defendants to the terrible publicity and grief that such cases can cause.
Indeed, this case evokes every parent's worst nightmare: A child dying after swallowing a common household object. The highest incidence of swallowed foreign bodies is in children between the ages of 6 months and 4 years. Young children put foreign objects in their mouths out of a natural sense of curiosity. Older children may swallow objects for attention, or due to psychological conditions or alcohol or drug abuse. In this case, the child was a victim of severe autism.
Eighty to 90% of swallowed objects pass through a child's digestive system without event, usually within two to five days. Often, such objects pass with no symptoms whatsoever. However, there are times when a child can swallow an item that is too large or too long to pass through the child's system, or an object that is sharp or poisonous. Those types of objects present tremendous risks to a child's health. For babies and small children, an object is too long to pass through a child's system if it is 1¼ inches or longer, and it is too large to pass if it is more than ¾ inch in diameter. For older children and adults, an object is too long to pass if it is 2 inches or longer, and too large to pass if it is 1 inch or larger in diameter.
In a scenario where a child has swallowed an object that cannot pass through his or her system, the most critical factor is detection. If detected within a reasonable time, almost any object can be surgically removed without severe harm to the child. If undetected, however, the presence of a foreign object can lead to death or severe injury if it cannot pass through the child's system. The injury to the child may result from aspiration or, as here, from the object becoming lodged in the child's digestive system. It is particularly dangerous when ingestion of a foreign body results in blockage of the small intestine. Due to the narrow diameter of the small intestine, many foreign bodies in this location cause a complete obstruction. At that point, immediate surgery is required.
Symptoms of a swallowed foreign object include choking; vomiting; bleeding in the throat; drooling; painful swallowing; pain in the chest, throat, or abdomen; gagging; refusal to feed; and bloody stool. Foreign objects may be detected by X-ray, sometimes enhanced with the swallowing of barium, or by endoscopy.
In this case, the physicians correctly suspected the swallowing of a foreign object, but negligently failed to confirm and treat the condition due to a very unfortunate failure of communication. There is plenty of blame to go around to all of the providers involved in the care of this child. However, Rosenblatt says, "The case revolves around who is 'on first,' as the saying goes, or who had primary responsibility." The decision by the pediatrician to admit the girl was consistent with her presentation. The ED physician followed up his suspicion of a possible obstruction by ordering an X-ray. "So far, so good," says Rosenblatt. Unfortunately, however, from that point forward, neither physician took responsibility, nor did either act to ensure that an accurate diagnosis was made.
Generally, as a provider of emergency services, it falls on the ED physician to ensure that any diagnostic evaluations, including radiology reports, are read and evaluated as soon as possible. This is the standard of care in emergency medicine. The ED physician was aware that there was no radiologist available. Without a doubt, he should have looked at the films himself or ensured that they were promptly read off-site, with the results telephoned to him or the attending pediatrician immediately. This process is referred to as a "wet read," meaning that it is done as soon as the films are developed.
Another blunder was when the pediatrician did not seek out information that would have confirmed the original diagnosis of a possible obstruction. Bowel obstruction is a serious, life-threatening emergency condition. If the girl's intestinal tract was obstructed, she would have required immediate surgery. "This is clearly not a 'wait-and-see' diagnosis," says Rosenblatt. A positive X-ray would have revealed the need for immediate surgery to relieve the obstruction, as at that point the identified object would not be at all likely to pass through without possibility of further, severe complications.
Rosenblatt urges, however, that there also is blame on the part of the radiologist, who would have read the film and should have realized the urgency of the situation. While he may have thought that the film had been read at the time it was developed, and that his report was a mere documentation formality, he should have taken the safest next step and notified the nurse by telephone of his findings. The very act of a specialty physician notifying a nurse of a serious situation should trigger that nurse to immediately notify at least the attending physician of those findings. Otherwise, the urgent situation becomes even more so, as no one is aware of the "ticking time bomb."
Had the radiologist not discovered the foreign object in the girl's small bowel, one could say that he was acting within the standard of care by merely dictating his report and letting it follow the usual course of transcription. At that point, the film would not have provided any additional information and the girl's condition would have been noted as stable. In such a scenario, the radiologist could not be held accountable for not doing something because there was no pressing evidence that he needed to. To the contrary, in this case the findings were positive, and there was an urgent need to communicate them to those that needed to know. Even if the radiologist thought that the report was a formality and that the results had been communicated, it is better to err on the side of redundant communications than to risk a communication lapse of the type that occurred in this case.
At this point, hospital policy would dictate who he was to notify. The policy may call for the radiologist to telephone the nursing unit, provide an immediate reading of the film, and fax a hand-written copy of the report to the nursing station to support his phone message. This is a common practice in hospitals, particularly where films are read off-site.
Another option would be the professional courtesy of notifying an attending physician directly that something is amiss with his patient. This does not bypass the notification to the nursing unit described above, but rather ensures that information gets to the pediatrician as quickly as possible so that he can act on it. Again, if the communication is redundant, that is fine. It is better to err on the side of patient safety.
In this case, any number of events could have occurred, any of which could have caused the report to be delayed. The report either was sent off for transcription, faxed to a wrong number, never retrieved from the fax, or filed prematurely before it was brought to the pediatrician's attention after it was received. Regardless of why the report was delayed, all parties to the care of this patient share in the blame for not seeking positive assurances of the outcome of the X-ray in a timely manner.
Additionally, the nurse may not have been aware that X-rays had been taken and that she should have been looking for the results. Patients transferred from one service to another, in this case the emergency department to a nursing unit, should be "handed off" in a manner that provides accurate and concise information as to the patient's condition and what had been previously done to stabilize the patient, including any diagnostics and available results.
"This brings up the standard of care regarding communication between providers," Rosenblatt says. In any medical situation, one caregiver has an obligation to "hand off all available information" while the other has an obligation to ask sufficient questions to ensure that they have gotten all of the available information. In this case, the nurse admitting the patient should have inquired as to what had transpired in the emergency department and whether any tests were pending. In fact, this entire situation could have been avoided if any of the professionals involved would have been more inquisitive and taken responsibility for the confirmation of the suspected diagnosis.
It was not until the child coded, went to emergency surgery, and then died that anyone was aware that a foreign object actually existed in her intestines. Had the emergency department physician ordered a wet read, thereby establishing the urgency of the situation and setting into motion a corrective action plan, the child might have survived.
Had the pediatrician followed up on the original premise that his patient may be suffering from a bowel obstruction and made the effort to inquire as to the radiology results, the child might have survived. And had the staff in the emergency department "handed off" the patient in the customary manner, where information is shared and appropriately acted upon, the child might have survived. Also, the nurse apparently never addressed the possibility of a lost X-ray report when the patient's condition deteriorated. She should have been proactive in seeking additional information.
In this case, the child suffered from severe autism. The fact that the child was in this condition and was unable to convey the fact that she had swallowed the rubber ball, certainly made it more difficult for the professionals to determine exactly what happened. However, the professionals were made aware of the child's history of swallowing objects and were on the right track in terms of ordering an X-ray and looking for an object. In fact, the X-ray ultimately revealed the object.
Nevertheless, due to a tragic lapse in communication, a patient whose condition had been accurately diagnosed did not receive the life- saving treatment that she needed. None of these professionals acted within the expected standard of care for such a situation. The jury appropriately found all of them liable. "Without a doubt, communication or rather a serious lack of it was the root cause of a most unfortunate situation," concludes Rosenblatt. In spite of the fact that it was clear to all parties that ingestion of a foreign body was a likely cause of this young girl's symptoms, and in spite of the presence of a radiology report accurately diagnosing her condition, simple miscommunication caused the tragic death of this child.