Bowel obstruction medical malpractice claim settles for $2M

Plaintiff claims doctors’ failure to order gastrografin enema or an abdominal CT was negligent.

Medical Malpractice Trial Report, 2007

Case summary: The plaintiff’s decedent was a 78-year-old man who died on April 9, 2004, from peritonitis due to ruptured diverticulum and perforation of the bowel.

On April 1, 2004, the decedent was first seen at Lowell General Hospital Emergency Department for complaints of constipation. He was discharged to home that day.

On April 5, 2004, the decedent returned to Lowell General Hospital Emergency Department with complaints of abdominal pain, cramping, nausea and vomiting, along with the increasing constipation. The decedent reported to the ER nurse that he had not had any stool following magnesium citrate, and minimal results following two Fleets enemas. A KUB x-ray was done at 3:47 PM and it revealed a large amount of stool throughout the colon suggesting constipation. There was no obvious small bowel obstruction. The decedent’s WBC was 13.7. His temperature was 99.4. Based on these findings, the ER physician admitted the decedent for evaluation and treatment and ordered a clear liquid diet, a fleets enema on arrival to the floor which could be repeated one time, a soap suds enema if no results from the Fleets enema, one bottle of Magnesium Citrate that night, and to call the GI the next day.

Over the following days, the decedent received Magnesium Citrate (4/5/04), Dulcolax (4/6/04), soap suds enemas (4/6/04, 4/8/04), and numerous Fleets enemas (3 on 4/5/04, 3 on evening of 4/7/04 to 4/8/04) without relief of his symptoms.

On April 6, 2004, nursing documented that after his soap suds enema, the decedent had yellow water with mucous returned. The decedent’s WBC was 14.0 at 7:00 AM. The attending defendant noted in his admission history and physical that the decedent abdomen was tympanitic, somewhat distended, firm and full, and with decreased bowel sounds. The attending defendant also noted that the decedent complained of lower left abdominal tenderness. By telephone, a gastroenterology (GI) consult was ordered with GI defendant #1 who described the abdomen as distended and tympanitic, and noted his nine-day history of constipation. This defendant’s assessment was constipation with question of large bowel obstruction, or a possible lesion. He ordered 1) the decedent not have nothing by mouth except for medications, 2) an IV be started and a nasogastric tube (NG) placed, 3) the KUB report be placed in the chart, and 4) to check with the attending in the morning whether to order a Gastrografin enema (dependent on the KUB result).

On April 7, 2004, from midnight to 6:00 AM, the nursing staff documented that the decedent had 3 frothy orange/yellow stools with a few brown flecks. That day, GI defendant #2 examined the decedent and noted his temperature was 100.5, WBC was 14.9, and his abdomen was distended. Later that day, the decedent was feeling better, but he had several episodes of vomiting and had passed 5 stools. The plan was to re-check the KUB, continue enemas, then clamp the NG, and if he tolerated this, they would begin a laxative and fiber supplement.

On April 8, 2004, the decedent’s stool tested positive for blood. GI defendant #1 examined the decedent and noted his abdomen was distended with decreased bowel sounds. At 9:00 AM a KUB was done. The findings showed new multiple dilated loops of small bowel along the left flank. There remained a large amount of retained fecal material throughout the colon. The etiology of the small bowel dilation was unclear. A CT scan of the abdomen was suggested for further evaluation as clinically indicated. No free air was seen. At 10:00 AM on April 8, 2004, the decedent complained of lower abdominal pain. The decedent was given morphine with poor effect. At 11:00 AM, the decedent’s stool again tested positive for blood. GI defendant #3 then examined the decedent and noted diffuse lower abdominal tenderness with abdominal distension and decreased bowel sounds. His plan of care was to continue the enemas, do serial KUB’s, continue Reglan and minimize narcotic use.

At 1:00 PM, a nurse administered a soap suds enema. At 2:30 PM, the decedent’s blood pressure was 95/64, pulse 114, color dusky and he was short of breath with chest pain. The attending defendant ordered IV fluid bolus, oxygen, and a respiratory consult. At 2:15 PM, the decedent was transferred to ICU. At 3:30 PM, he was taken to the operating room for an exploratory laparotomy. Liters of fecal material were found in the peritoneal cavity, as well as all quadrants of the abdomen due to the rupture of large diverticulum which lead to colonic perforation. Postoperatively, he was again taken to the ICU with peritonitis due to fecal contamination, sepsis syndrome and multiorgan failure.

On April 9, 2004, the decedent went into cardiac arrest, and could not be resuscitated despite pharmacologic and electrocardioversion therapy. He was pronounced dead at 4:13 PM. Final autopsy diagnoses confirmed Mr. Fahey’s death was due to acute diverticulitis with perforation, and peritonitis. Gross and microscopic analysis of the sigmoid colon revealed perforated diverticulitis, pericolonic abscesses, a fissuring colonic ulcer and a sterocoral ulcer with perforation. The large intestine was dilated, with a maximal luminal circumference of 18.0 cm.

The plaintiff claimed that the defendants were negligent when they failed to order an immediate gastrografin enema, or an abdominal CT. The plaintiff also claimed that the defendants failed to start IV antibiotics. The plaintiff further alleged that the decedent should not have been given bowel stimulants (e.g. Reglan), laxatives (Dulcolax and Magnesium Citrate) and enemas for fear of rupturing the infected diverticulum and thus the bowel, leading to peritonitis, and possibly death.

The plaintiff alleged that as a direct result of the defendants' deviation from the standard of care as outlined above, the decedent not only suffered a significant delay in diagnosis and treatment of his infected diverticulum, but also suffered aggravation of it by enemas and laxatives. This led to the plaintiff’s decedent’s untimely death.

The defendants contended that they were not negligent and that nothing they did or failed to do caused or contributed to the decedent’s death.

The case settled during discovery for $2,000,000.

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

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