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Death of Forgotten Patient in Emergency Room Caused by Inattention

April 13, 2020

Imagine a loved one in Michigan heads to an ER for treatment. She’s relaxing in a wheelchair and loses consciousness.

What if no one bothered to check on her until she was wheeled down to the morgue?

That is precisely what happened at a Pennsylvania emergency department. A patient was found unresponsive in the ER and was later pronounced dead. And, it was captured on camera. Hospital security footage showed medical staff repeatedly passing by the patient who was in the hospital for hours. The emergency staff at WellSpan Hospital in York, Pennsylvania are captured on video walking past a patient in a wheelchair approximately 12 times in the course of a day. The video records show that no one approached the patient for 3½ hours after arriving at the hospital by ambulance,  and by the time they noticed, the patient was dead. “This was a rare event that occurred in our emergency department at WellSpan York Hospital,” Vice President of Medical Affairs Dr. Allan Birenberg said in a statement. “We take seriously our commitment to provide safe, timely, compassionate care to everyone who walks through our doors.

In the case of the forgotten patient, the Pennsylvania Department of Health determined that WellSpan York Hospital was out of compliance with the state’s Medical Care Availability and Reduction of Error Act after special monitoring visits were conducted. The law requires that the hospital is to report the death within 24 hours. An investigation confirmed that the report wasn’t entered until after the facility conducted a “Root Cause Analysis,” which is in violation of the law. The law specifically provides that the “report will not be delayed for peer review or other quality investigating activities.”

The Investigation

The investigation showed the patient arrived by ambulance just before 10 AM on August 16th complaining of nausea. The emergency room triage notes say the patient had complained of dizziness since the night before and had a history of vertigo. His temperature was low, and staff members were having a hard time getting a pulse oxygen reading. Fifteen minutes later, the emergency room staff determined the patient had no signs/symptoms of sepsis. He was given an acuity level of 3, and the triage was completed. A few minutes later, the patient’s acuity level was downgraded to 2.

At 10:25 AM, five minutes later, he had a heart rate of 120, respiration at 28, and his blood pressure was 115/89. At that point, until 12:05 PM, the patient’s name was called three times, but he failed to respond each time (he may have been unconscious!). After the third time, the patient was marked “LWBS” (left without being seen), and his name was taken off the tracking board. Twenty minutes later, at 12:25 PM, the patient was found to be unresponsive, according to the report. He was transferred to a private treatment room and was pronounced dead at 1:31 PM.

Caught on Tape

Investigators reviewed the security camera footage, which showed that the patient’s oxygen was discontinued when he was transferred from the ambulance stretcher to the wheelchair at the ER. The video also shows his vital statistics being taken by a nursing assistant, but that the pivot nurse (responsible for identifying each patient and comparing to the tracking board) never spoke with him. “At no time was any staff observed to complete Rounding on [the patient] as per their Rounding policy,” the report says. “No movement by the patient was noted from approximately 11:09 a.m. until approached by staff at 12:20 p.m.” In addition, the report found that two other patients with less-severe medical issues were triaged, examined, and discharged while our forgotten patient was still in the waiting room.

Contact a Med Mal Attorney in Michigan

Doctors, emergency rooms, and healthcare facilities make mistakes, and some of these errors can be fatal, like the one in the Pennsylvania ER.

At Buchanan Firm, our combined legal-medical team has decades of successful experience handling medical malpractice cases, including cases involving surgical errors, incorrect medical diagnoses, and lack of medical care. Our medical professionals at the law firm can speak to you immediately and review your claim. Our team of Michigan medical malpractice lawyers can quickly and efficiently assesses the medical facts and takes immediate action to protect your legal rights.

Please contact us today.