By Damian D. Capozzola, Esq.
The Law Offices of Damian D. Capozzola
Los Angeles
Jamie Terrence, RN
President and Founder, Healthcare Risk Services
Former Director of Risk Management Services
(2004-2013)
California Hospital Medical Center
Los Angeles
News: A 19-year-old man complained of a cough, congestion, and fatigue for two weeks. The patient sought treatment and a chest X-ray was ordered for five days later. In the interim, the patient’s condition deteriorated, and he again sought treatment. Physicians at the second visit did not escalate his care despite abnormal vital signs, significant swelling in his legs, and difficulty breathing. One day later, the patient died from myocarditis.
The patient’s family filed a lawsuit, claiming that the failure of the physicians at the second visit to diagnose, treat, or escalate his care constituted malpractice that caused the patient’s death. The defendants denied liability, but a jury awarded the plaintiffs $14 million.
Background: On Dec. 12, 2016, a 19-year-old man sought treatment for a cough, congestion, and fatigue which had lasted nearly two weeks. Providers at a local clinic ordered a chest X-ray, scheduled for Dec. 17. However, his condition worsened.
On Dec. 17, the patient’s mother notified the clinic that her son was experiencing swelling in both of his legs. She requested that a physician examine her son again before the X-ray appointment, but the clinic’s staff told her that such an examination was unnecessary. The staff told the patient’s mother to continue with the imaging and that a physician would call them following the scan if something unusual was discovered.
On Dec. 19, the patient returned to the clinic as his symptoms continued to worsen. The patient presented with edema in his legs, oliguria, hypotension (blood pressure 90/60 mm Hg), and hyperpnea (respiratory rate 40/min). He was seen by two of the clinic’s physicians. Neither physician documented any of the treatment or care that they provided to the patient, nor did they recommend admitting the patient to the hospital. Instead, the patient was sent home.
One day later, on Dec. 20, the patient was transported to a hospital via ambulance, suffering from difficulty breathing and critical vital signs. When he arrived at the hospital, he was in critical condition and died approximately two hours later. According to the death certificate, the patient died of supraventricular tachycardia and acute myocarditis.
In 2018, the patient’s parents and sister filed a lawsuit against the medical practice group and two physicians who evaluated the patient at the Dec. 19, 2016, visit. The patient’s family alleged that the physicians and practice group were negligent on several bases, including failing to administer an accurate assessment of the patient, failing to hospitalize the patient, failing to treat his abnormal vital signs, and more. The patient’s family argued, supported by testimony from experts, that had the patient’s myocarditis been timely diagnosed and treated, he would not have died. An expert for the family — a board-certified cardiologist — testified that the defendants inaccurately assessed the patient and failed to hospitalize him or escalate his care based on his symptoms and abnormal vitals. The defendant medical group and physicians denied liability.
A jury found the practice group and physicians liable for failing to diagnose and treat the patient’s heart condition and awarded the plaintiffs $14 million.
What this means to you: This case highlights a common type of medical malpractice: diagnostic errors, including failed or delayed diagnosis. A study in 2017 revealed that 22% of paid malpractice claims were diagnosis-related and were associated with higher probabilities of significant disability and death compared to minor injuries. (https://psnet.ahrq.gov/issue/m...) Diagnostic errors can result in a wide range of consequences, from those causing no harm based on errors quickly remediated or those causing significant harm, such as the patient’s death in this matter. A different study by Johns Hopkins researchers revealed that diagnostic errors resulted in significant permanent injury or death annually in the United States for 80,000 to 160,000 patients. (https://www.hopkinsmedicine.or...)
In this case, two medical care providers evaluated the patient on Dec. 19, yet neither of them took appropriate action to diagnose the patient’s condition. Moreover, this was not an issue of a lack of information — the physicians knew of the patient’s edema, oliguria, hypotension, and hyperpnea. According to the plaintiffs’ expert, these symptoms and abnormal vital signs demonstrated that the patient was critically ill and in need of emergent care, hospitalization, and escalation of treatment. The significance and critical nature of his status on Dec. 19 is confirmed by the rapid deterioration that resulted in the patient seeking emergent care on Dec. 20.
The plaintiffs’ expert noted that if either physician had correctly diagnosed the patient’s condition on Dec. 19, medical professionals could have taken steps to immediately stabilize the patient, and his short-term and long-term prognosis would have improved. Most critically, the expert testified that the patient’s death was preventable, thus the diagnostic error caused the patient’s death. For medical malpractice cases, causation often is an element subject to challenge by defendants. If the defendant care provider can show that there are intervening items that contributed to or caused the patient’s injury, then the link may be broken between the physician’s negligent act and the patient’s injury. But when the expert testified about the direct link, and there was only one day between the diagnostic error and the patient’s death, the plaintiffs proved the element of causation.
While it is clear that the physicians did not appropriately diagnose the patient, it is unclear what treatment or care the physicians did provide or purported to provide. This reveals another important lesson for care providers: Documentation is critical, not only to appropriately treat patients but also to defend against subsequent claims of malpractice. Written medical records are important for appropriately treating patients because it is easy for test results, diagnoses, treatments, recommendations, and other relevant medical information to be lost in the transition between or among care providers. Detailed and consistent medical records help ensure the patient’s entire care provider team is working with the same set of information and allow for effective multidisciplinary care. By contrast, failing to keep adequate records may result in duplicated work by care providers or information simply getting lost.
For litigation, adequate records also enable defendant care providers to demonstrate with more persuasive force that appropriate care was provided. Memory inherently fades over time, and with care providers treating hundreds or thousands of patients, it is easy for a single patient’s history and treatment to be a blur. Medical records suffer from no such vulnerability — it is easy to store thousands of patients’ worth of data, particularly in electronic form. The timeline is demonstrative: The few days at issue were in December 2016, yet the trial and verdict occurred in December 2023. It is unlikely that the physicians involved recalled the specific details of the patient’s visit seven years later. While a jury may be sympathetic toward a physician’s inability to recall details from many years ago, it is far more effective to have a written record confirming that the physician accurately diagnosed the patient and provided treatment, compared to the physician’s word that they did so.
Note also that this patient presented initially with symptoms he had experienced for two weeks. A chest X-ray at that time would have been appropriate. An assumption that a young adult is not prone to illness is a dangerous one. When that same patient presents a second time with worsening symptoms, that same assumption may well comprise negligence. If assumptions must be made, a safe one that would meet the standard of care should be that a young adult would have recovered quickly and that symptoms lasting two weeks are indicative of a serious condition that requires treatment. But from the risk perspective, there can be no assumptions made in the healthcare setting.
The elderly often are plagued by edematous lower extremities as are pregnant women in their third trimester on a hot summer day. It is not a frequent symptom for 19-year-old men. In fact, it is a significant indicator of circulatory collapse due to a serious cardiovascular condition for which immediate care is required. In sum, the young man’s care providers rendered insufficient care. Indeed, without a complete entry into the patient’s medical record, an assumption may well be made by the legal system that no treatment was provided. Assumptions can be useful tools for plaintiff attorneys when the standard of care cannot be supported by the documentation required by state and federal regulations. The medical record, whether written or electronic, is a legal document — and may be the only proof of care or the lack thereof.
Finally, the high damages figure in this case is directly related to not only the severity of the malpractice, which resulted in the patient’s death but also related to the patient’s age. Care providers take patients as they are — a young patient, such as the 19-year-old here, who requires a lifetime of treatment or whose life is cut short, can result in the type of multimillion-dollar verdicts as here. This does not mean that special care should be provided to young patients, but it can inform defendant care providers in evaluating potential or actual malpractice litigation in terms of negotiating a settlement. Understanding that a jury may award a patient’s family eight figures given a young patient’s significant injury or death helps analyze a case and potentially prevent such a large, public, adverse award as the care providers may be able to resolve the litigation earlier and for less while keeping a settlement confidential.
REFERENCE
- Decided Dec. 8, 2023, in the Circuit Court of Cook County, Illinois, Case Number 2023L002995.
This case highlights a common type of medical malpractice: diagnostic errors, including failed or delayed diagnosis.
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