Risk Management Monthly / Emergency Medicine - Case of the Month, January 2018

Here’s a case filed in 2013 against a hospital, its staff, and a contract NP and emergency physician in the ED, involved a seven-week-old child brought to the ED with a chief complaint of “blood in the mouth” and fussiness. The clinician’s note did not include this finding, but the nurse had documented blood in the mouth, facial bruising, and an eye injury that the child’s teenaged mother attributed to the child “hitting himself in the face.” Six weeks after this visit the child returned to the ED with a spinal cord injury, fractures of the clavicle and ribs, and extensive generalized bruising. The child, now paralyzed, was placed in foster care and subsequently adopted.

• In the malpractice lawsuit, the plaintiffs contended that California legislation required that the hospital and emergency medical corporation provide its employees with information on child abuse reporting laws and have them sign an acknowledgment that they were aware of the mandatory reporting status.
• It was also asserted that evaluation to rule out child abuse at the time of the initial ED visit (e.g., by ordering a skeletal survey) would have identified old fractures. Former CPS employees testified that, had a report been filed, the child would have been taken into protective custody at that time.
• The plaintiffs had requested payment in the amount of the $1 million policy limits of the involved clinicians (a possible reason not to have high limits for your malpractice insurance policy). The hospital offered $200,000. The plaintiffs’ final pre-trial demand was $5,725,000. At trial, the ultimate verdict was $4.1 million in economic damages and $4.3 million in non-economic damages.
• The RMM panel advises:
• Look at the nurses’ notes and address any discrepancies between those notes and your findings. Communication between physicians and nurses is critical.
• The physician is not in a position to state that child abuse exists, but rather to say that there is sufficient information to prompt an investigation.
• If child abuse is felt to be a possibility, implement the elements of a child abuse protocol and request a skeletal survey to identify old injuries.