$3.5M settlement for wrongful death related to misread CT scan

2005 Medical Malpractice Settlement Report

Failure to properly respond to symptoms and abnormal imaging studies results in death of 26 year-old woman

In October 1996, the plaintiff’s decedent was a 26 year-old mother of a 10-month old baby boy. The decedent carried a fifteen year history of systemic lupus as well a mild history of thrombocytopenia (decreased platelets) and other abnormalities of the proteins in her blood, all of which, collectively, placed her at increased risk for thromboembolic events.

On 10/26/96, the decedent was examined by defendant #1 due to a two-day history of headache and upper neck pain. Defendant #1’s impression was "recent headaches without evidence of an infectious or focal neurologic problem, possibly secondary to steroid treatment; doubt rufous vasculopathy" (illness of the blood vessels). No imaging studies or diagnostic tests were performed and the decedent was instructed to call the office with a progress report in two days.

The next day, on 10/27/96, the decedent called the defendant’s office reporting that her headache remained unchanged and was presently right-sided. Although she remained symptomatic, no diagnostic testing including an immediate MRI and blood studies to rule out a thromboembolic event were ordered.

The headache did not resolve and later that same day (10/27); the decedent presented herself to the hospital Emergency Room complaining of a severe frontal headache, nausea and photophobia. Defendant #2, the ER resident, and Defendant #3, the ER attending, obtained a head CT scan and lumbar puncture. The CT scan was performed and interpreted by Defendant #4, an attending radiologist. During the interpretation, the ER resident was present and listening to the attending radiologist’s comments and findings.

According to the ER resident, the radiologist communicated that this was a normal imaging study. The ER resident stated that he was not given any information that would lead him to believe that this was an abnormal study or that any further imaging studies were required. The ER resident returned to the emergency room and informed the attending ER physician and the patient that the CT scan was within normal limits. At that time they proceeded with a lumbar puncture to rule out an infectious process and this was negative. Based on the negative testing that was done, the decedent was sent home with a prescription for pain medication and instructions to follow-up with her primary physician the next day.

Despite the resident’s statement that the CT scan was normal, the radiology report which was generated some hours after the interpretation clearly states that this was an abnormal CT scan. In fact, the report states that the scan showed a possible subdural hematoma and a possibility of venous thrombosis of the transverse and sagittal sinus. These clinical findings warranted immediate intervention. The defendant radiologist also testified that when he interpreted this study with the ER resident in attendance he clearly communicated these abnormal findings consistent with what is written in his report.

On 10/28/96, the decedent called her primary physician, Defendant #5, complaining of a persistent severe headache in the frontal region and nausea and vomitting. This defendant noted that the head CT scan performed on the previous day "was reportedly negative". There is no indication in the medical record that this defendant personally reviewed the scan or the report, nor did he obtain further diagnostic studies, including an immediate MRI, to determine what was causing this persistent and severe headache. He instructed the decedent to call the next day with an update. As instructed, the decedent called the next day (10/29/96) on two occasions, reporting vomitting, an elevated temperature and a bad headache despite taking Fioricet. She also reported that her head felt big, and that she was hardly urinating. Defendant #4, with knowledge of her history and her progressive symptoms, once again deviated from the accepted standard of care, failing to obtain diagnostic imaging and blood studies.

The next day, 10/30/96, at 10 a.m. and 12:30 p.m., the decedent again spoke with Defendant #4’s office, stating that she still had a headache, and felt "strange and spacey", and was too weak to take her medicine. An outpatient brain MRI was ordered and performed later that day at a freestanding clinic, with findings consistent with "sagittal sinus thrombosis and possibly more extensive thrombosis with secondary small acute bleed or hemorrhagic infarct in the left posterior parietal region". These findings required immediate intervention with anticoagulation therapy. However, Defendant #4 did not call for or obtain those results on that date. Rather, that evening, after completion of the MRI, the decedent brought herself to the hospital emergency room with complaints of worsening headache and discomfort and was noted to have swelling around her eyes. A head CT scan was performed, "showing sinus thrombosis of the straight sinus and the right transverse sinus", and suspicion of "sinus thrombosis of the superior sagittal sinus". Additionally, "two areas of cortical hemorrhage in the high left parietal lobe" were seen. She had definite progressive changes evident by imaging studies as well as clinical neurological changes. She demonstrated weakness of her right arm and was dragging her right leg while walking. She was admitted to the hospital and further imaging revealed extensive thrombosis of sagittal and transverse sinuses, new hemorrhage in the right temporal parietal lobe, and several hemorrhages in the left parietal lobe. Within hours of her admission her prognosis became grave, and she continued to neurologically deteriorate, rendering resuscitation measures futile at that late stage. She became obtunded; with minimal motion now in her other extremities. A follow-up head CT showed right-sided intracerebral bleed with herniation, sagittal sinus thrombosis, midline shift and signs of impending downward herniation. She was determined to be brain dead by protocol on 11/1/96 and died after organ donation.

The defendant radiologist argued throughout that his interpretation and communication of the initial CT scan was accurate and that the abnormal results were made known to the ER resident. The ER resident conversely argued that he was told all findings were within normal limits. It was anticipated that at trial these defendants were going to have to concede that, at the very least, there was a communication error between the two parties. The other defendants argued that they relied upon a reportedly normal or negative CT study and thus did not feel it was necessary or appropriate to order further imaging studies of the brain. They argued her symptoms were consistent with her prior history of lupus.

The decedent left behind a young son who was 11 months old at the time of her death. The week prior to trial a settlement was reached in the amount of Three Million Five Hundred Thousand ($3,500,000) Dollars.

Lubin & Meyer attorneys represented the plaintiff in this medical malpractice lawsuit.

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