Boy Died After Doctors Failed to Detect Infection

When a 12-year-old boy complained to his parents earlier this year about what they believed might just be a bellyache, they took the responsible step of first taking him to their pediatrician and then to a hospital emergency room when the pains persistence. Both doctors seemed to concur that all he needed was a little medicine in order to settle his stomach. But three days later, his parents discovered that he was dead, a victim of medical malpractice.

The child had suffered a cut on his arm while playing basketball at school. By midnight that day, he was vomiting at home. When he saw the family doctor, he had severe pain in his leg, as well as a high fever, and skin that, when pressed, did not quickly resume its normal color. The doctor thought it was just a stomach problem, and recommended that he be taken to an emergency room for further examination and some intravenous fluids. The emergency room doctor thought that his condition was improving and gave him some anti-nausea medicine to take at home.

The child had an infection that the doctors had not detected or treated. That infection grew and caused septic shock that ended his life. Many say that this shocking case is a clear sign that enhanced efforts are needed by doctors and hospitals nationwide to better detect sepsis at an early stage.

A number of problems clearly contributed to the child’s death. Some laboratory test results that could have helped identify the nature of his problem were not communicated to the doctors. Many knowledgeable about medical practice in this country say that this is an egregious type of error that takes place all too often.

Additionally, some of the family pediatrician’s observations about the child’s symptoms, that could have aided the emergency room doctor in understanding the development of his illness, were not included in the information passed along. The initial diagnosis given to the child’s illness may have been in keeping with a few of his symptoms, but clearly, the doctors should have explored alternative explanations and examined him further.

There were a number of symptoms that pointed to the serious nature of his problem, including his mottled skin, his rapid pulse, that persisted over time, and problems with a significantly low number of platelets found in hospital lab tests as well as an abnormally high volume of immature white blood cells.

Among the measures some hospital emergency rooms are experimenting with in response to this tragic death are the use of expanded checklists to make sure no important step in the examination is missed, making sure that time is taken to give parents medical test results, and entering a patient’s known symptoms into high technology devices such as training robots that can provide suggestions.

The case has already been the subject of much needed discussion at a medical conference, as well as a presentation by the boy’s father at a medical academy. What is frightening is that many doctors admit that these kinds of errors are all too familiar.