Critical flaw discovered by a defending attorney after the plaintiff’s attorney had spent thousands of dollars bringing the case to discovery.
a. 25 yr old woman in third pregnancy with one living child; first pregnancy had a compromised outcome
b. Premature rupture of membranes at 34 weeks of pregnancy; stabilized and transferred to antepartum unit to wait for pregnancy to reach 36 weeks, a common practice at this time
c. Sudden onset of bleeding and pain at 35 ½ weeks; fetal monitoring shows fetal distress; to OR and baby delivered within 8 minutes of primary nurse entering patient’s room
d. Mother had significant blood loss but fully recovered; baby needed extensive resuscitation but died two days later
e. Claim was made against the primary physician, admitting physician, and primary care nurse. Basis of the claim was that the patient’s call for help was not answered for twenty minutes by primary care nurse. This was substantiated by the patient’s husband watching the clock on the wall of the room.
Two vital errors were made by the plaintiff’s attorney that could have been identified by a legal nurse consultant:
1. He did not ask the primary care nurse what her patient load was at the time of the incident. There had been layoffs on the unit at this time. The incident also occurred during a time of night when nurses commonly take a one hour break and patient loads can be heavy. On this night, the primary care nurse was caring for six triage patients, an early labour patient and two antepartum patients which she had told the nurse in charge was too heavy for patient safety. However, the primary care nurse was never obliged to give him this information during discovery.
2. He did not confirm the actual presence of a clock on the wall of the patient’s room for her husband to time the response time. This unfamiliarity with hospital layout and the custom of clocks on the walls of rooms in other parts of the maternity unit cost the plaintiff their claim against the primary care nurse and wasted the attorney’s resources in preparing the case as well as three hours in discovery with the primary care nurse.
Patient with complex medical issues who suffered permanent injury during delivery. Defended on pre-existing condition and extent of damages.
a. 20 yr old woman with third pregnancy delivering first baby at 37 weeks; two miscarriages
b. History of drug use during pregnancy as well as “mild” high blood pressure
c. Rapid labour and delivery
d. Patient admitted to neurology unit after delivery with diagnosis of stroke and continues to suffer from neurological deficits
A summary of the hundreds of pages in the chart plus additional research from other sources brought forward the following additional information for the defending attorneys to use in their argument of pre-existing condition:
1. Prior to her prenatal care, the patient had not had routine health checkups with a family physician since she was a small child. Since her blood pressure readings were in the higher range of normal from the onset of prenatal care, it is possible that she had essential hypertension that had not been previously diagnosed, especially in light of the normal results from blood work and other tests performed during her pregnancy and hospital stay.
2. Neurological research indicates that women with a history of miscarriage have an increased risk of stroke due to the increased creation of blood clots in their bodies. The research is based on the theory that some miscarriages can be caused by the mother’s tendency to produce clots which stop the blood supply to the developing embryo.
3. The attending physician had made a post-delivery diagnosis of placental abruption (placenta had separated from the wall of the uterus prior to delivery) based on the patient’s symptoms as reported to her by the primary nurse as well as examination of the placenta following delivery. Placental abruption can occur in patients with pregnancy induced hypertension as well as patients who have used drugs such as cocaine just prior to or during labour.
4. The patient’s behaviour was charted by the primary care nurse as well as by other nurses. The behaviour they described was consistent with recent drug use. A drug screen was not ordered to be performed during admission on the labour and delivery unit. The patient denied drug use when questioned by the primary care nurse.
5. Rapid labour and delivery is common when a woman has recently used drugs such as cocaine and the patient had left the unit with her boyfriend within thirty minutes of the onset of the rapid labour and symptoms of placental abruption. However, rapid labour and delivery is also a classic symptom of pregnancy induced hypertension.
6. The baby was admitted to Neonatal Intensive Care with signs and symptoms of drug withdrawal. Toxicology screening on the baby revealed cocaine in the baby’s bloodstream which indicated maternal use of the drug within a brief period prior to delivery.
A legal nurse consultant can pick up the medical-technical nuances of a case that can be missed by an attorney. These nuances can be used in discovery to establish merit in a case.
a. 33 yr old woman delivering first child at term
b. History of one antepartum admission at 34 weeks gestation for undiagnosed abdominal pain
c. Chart shows unusual pattern of bleeding during labour
d. Maternal death in ICU following spontaneous delivery; cause of death was suspected amniotic fluid embolus (tiny debris from the uterus forms a ball and enters an open artery) which was confirmed on autopsy
A review of the chronology of events was completed by the legal nurse consultant. As well, she reviewed the standards of care for physicians and nurses in the obstetrics, anaesthesia, operating room, recovery room and ICU. She was also able to determine the qualifications and experience of the staff involved. In addition to the patient chart, the legal nurse consultant also asked for all relevant safety learning (incident) reports completed by the staff following this incident. The legal nurse consultant also met with patient’s husband to establish his recollection of events.
1. The safety learning reports were completed by the primary nurse, the nurse she was orientating to the unit and the charge nurse. The primary nurse had been working on the unit for over twenty five years. The nurse being orientated had ten years of obstetrical experience but had not practiced for two years. The charge nurse was new to the role and had not undergone any specialized training in the charge nurse role. She had five years of nursing experience with three of them being in maternity care.
2. The timeline for recognition and treatment of the patient signs and symptoms reveals that there was a delay in the labour and delivery room in beginning the resuscitation of the patient during an early phase of the crisis.
3. The safety learning report and the charting on the patient that were completed by the nurse being orientated revealed that she had identified there was a problem immediately after delivery. The patient’s husband confirms that the nurse kept telling the doctor there was a problem. The patient had rapidly become unstable, was losing consciousness and losing blood at an alarming rate. The obstetrician was doing a procedure to repair a tear while teaching a resident and told the nurse that the patient was merely “hysterical.” It took the nurse over ten minutes to convince the attending physician that the patient was critically ill. She noted that blood loss was four times the physician’s estimate based on her actual measurements by established standards and was most of the patient’s normal blood volume.
4. Once the critical situation was recognized and acknowledged, the resuscitation process was activated. According to the safety learning reports completed by the two primary nurses, the charge nurse entered the room and physically pushed nurses away from the patient and began to perform direct patient care. It was apparent that she did not understand her role of coordinating the team of nurses, ensuring necessary physicians were called, establishing that critical functions such as ordering blood products and calling for specialized staff were completed and that the operating room should be ready for a highly emergent procedure. There was a significant delay while other nurses performed these duties for her once they realized these tasks were not being done. When the patient was transferred to the operating room, the OR team was not ready to receive her and there was not a nurse readily available to assist the anaesthesia team.
5. There is a 40% survival rate for amniotic fluid embolus in developed nations. However, this survival rate is based on rapid recognition and treatment of this devastating deterioration of a healthy young woman. Patients who have partial separation of the placenta during pregnancy and childbirth are at increased risk of developing this condition. This patient ‘s admission for abdominal pain during the late pregnancy as well as increased bleeding during labour would suggest that she had this increased risk. The two primary nurses appear aware of the risk. The obstetrician appears to not have acknowledged the risk even in the face of overwhelming signs and symptoms.
6. The patient’s husband was still in the grieving process. He was unable to cope with the demands of his small daughter which reminded him of the sudden loss of his wife. Child care has been hired to assist him. He reported that he has difficulty sleeping because he relives the shocking moments of large amounts of blood, yelling voices and chaotic activity before his wife left for the operating room. He has been required to undergo psychiatric treatment for post-traumatic stress disorder. He had been unable to return to work and was forced to resign from his position with a well established firm.