Family sues in operating room fall

Published by The Boston Globe, January 29, 2008
By Jonathan Saltzman

Moments after undergoing surgery to replace a broken hip, an 86-year-old Dorchester woman fell from an operating room table at Boston Medical Center, causing a massive head injury that killed her a week later, her family said in a lawsuit filed yesterday. Catherine O'Donnell fell, buttocks first, through a gap in an orthopedic surgical table on Oct. 6 after a nurse removed a safety strap around her torso as medical staff prepared to transfer her to a hospital bed, according to an investigative report by the state Department of Public Health.

O'Donnell, who was still under anesthesia and had a breathing tube in her mouth, struck her head on the floor, fracturing her skull and causing internal bleeding, said the Health Department report. She died Oct. 13 despite a second operation that removed part of her skull to relieve pressure from the bleeding.

"Obviously, everyone has to go, but for her to go in this manner and for us to have to make those decisions for the family is terrible," said her son, Tom O'Donnell, who reluctantly decided with his two sisters to remove their mother from life support after doctors told them her prospects were grim. "We want assurances that you can go into that hospital and not have this happen to someone else."

The wrongful-death suit filed in Suffolk Superior Court names four defendants who were allegedly in the operating room at the time: Dr. Carlos Guzman, an anesthesiology resident; Dr. John Pryor, an orthopedic resident; and two nurses, Harvinder Miller and Ingrid Rush.

Ellen Berlin, a spokeswoman for Boston Medical Center, said the hospital extended its sympathy to the O'Donnell family. She said the medical center had changed procedures to prevent similar accidents from happening, but declined to be more specific.

"We regret that this tragic accident occurred and are sorry for the pain it has caused the O'Donnell family," Berlin said.

Paul Dreyer, director of the Health Department’s Bureau of Heath Care Safety and Quality, said he reviews about 800 serious injuries and medical errors involving patients at 90 Massachusetts hospitals a year. About 400 to 500 involve patients hurt in falls. He had no figures on falls from surgical tables, but said it was unusual.

O'Donnell, a lifelong resident of Dorchester who loved to bake for her grandchildren, broke her left hip after she fell near her bed in her first-floor apartment, said her son.

The woman, who stood 5 feet tall and weighed 123 pounds, underwent surgery to repair the hip at Boston Medical Center in the early afternoon of Oct. 6, her son said. Tom O'Donnell said he spoke with her in the hospital shortly before surgery and kissed her goodbye, never thinking it would be the last time he would talk with her.

She was placed on a special surgical table designed for such procedures, according to the Health Department investigators who interviewed hospital staff in November. The table features special boots to immobilize patients' feet and a large opening near the base of their torso that enables doctors to take X-rays easily.

The surgery was uneventful, said the Health Department report, provided to the Globe by the O'Donnell family’s lawyer, Andrew C. Meyer Jr. What happened next was extraordinary.

The medical staff removed O'Donnell’s feet from the boots, bandaged her wound, and changed her gown, the report said. A nurse identified by Meyer as Miller removed the safety strap around O'Donnell’s torso and walked toward the patient’s left side, so a bed could be placed on the right side and the patient could be transferred.

As the nurse began walking, "she looked at the patient and saw (with horror) that she was falling from the table, buttocks first, through the opening between the torso and the lower leg table sections," said the report.

The nurse told investigators that she lunged toward O'Donnell, but that the patient fell through the gap and struck her head on the floor.

Guzman, the anesthesia resident, told investigators that he was at the head of the surgical table when he heard the blood pressure cuff begin to deflate, said the report. He looked up at the blood pressure monitor and then glanced down in shock to see O'Donnell fall.

The investigative report said the hospital did its own "root cause analysis" and determined that the doctors and nurses in the operating room were preoccupied with their own tasks and that the "removal of the . . . safety belt from the patient was not verbally communicated."

The hospital has adopted a protocol requiring all nurses and doctors put their hands on the patient before removing the safety belt and making sure that there are people on both sides of the table.

Hours after O'Donnell fell, she underwent surgery to relieve the pressure of the bleeding. But Tom O'Donnell said she never regained consciousness.

Meyer, who has been a medical malpractice lawyer for 30 years and has won some of the state’s biggest judgments in such suits, said he has never encountered a case of a patient dying as a result of a fall from an operating table.

"This is a case involving clear neglect with a horrifying outcome," he said.

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