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No Breach of Care in Treatment of Pressure Ulcers Leading to Sepsis, Death


A 68-year-old morbidly obese woman with diagnosed degenerative joint disease, diabetes, hypertension, arthritis, and gout, as well as a history of diabetic coma, stroke, and heart bypass surgery, was admitted to the hospital with severe hip pain. The woman had been unable to walk for three days due to severe pain in the left hip. The doctor who treated the woman at the hospital believed the woman needed a hip replacement. The doctor recommended that the woman undergo a course of rehabilitation to improve strength prior to surgery.

 

Approximately five weeks later, the woman was transferred to a rehabilitation facility. At the time of the woman’s admission, the rehabilitation facility’s staff documented multiple areas of skin breakdown on the woman’s body, including two bedsores (pressured ulcers) on the buttock. One sore measured three and a half centimeters by one centimeter, and the other measured two centimeters by one centimeter.

 

While the woman was at the rehabilitation facility, the two pressure ulcers deteriorated and became infected. Twelve days after the woman was admitted to the rehabilitation facility, one of the pressure ulcers developed slough. The primary physician ordered that Santyl (a chemical debriding agent) be applied to the wound.

 

Twenty-two days after the woman was admitted to the rehabilitation facility, the woman was transferred to the emergency room (ER). The woman was diagnosed with an altered mental state (a possible symptom of an infection), severe anemia, and acute renal failure, along with dehydration, diabetes, and hypertension. The woman was immediately started on IV fluids for the dehydration and antibiotics for the infected wounds and possible sepsis. The woman’s dehydration resolved. One month later, the woman died of acute respiratory failure caused by sepsis.

 

The woman’s estate filed a wrongful death and medical malpractice claim against the rehabilitation facility, the woman’s primary physician at the rehabilitation facility, and the primary physician’s practice group. The complaint alleged that the rehabilitation facility failed to notify the woman’s doctors of changes in the woman’s condition in a timely fashion. Regarding the primary physician, the complaint alleged that treatment of the woman did not meet the standard of care.

 

The case proceeded to a jury trial.

 

The woman’s expert in the field of nursing testified that the rehabilitation facility had breached the nursing standard of care when its staff did not provide prompt notification to the woman’s physicians of changes in the woman’s condition, including the worsening of the pressure ulcer, lethargy, reduced intake of foods and fluids, and dehydration.

 

The woman’s expert geriatrician testified that issues related to the woman’s dehydration were resolved once the woman was transferred to the hospital. Regarding the primary physician, this expert testified that standard of care required the primary physician to treat the wound with both a debriding agent and a topical antibiotic. He also testified that it was more likely than not that the woman would have survived if the primary physician had ordered a topical antibiotic when the wound developed slough. On cross-examination, the woman’s expert geriatrician acknowledged that reasonable doctors could disagree about the use of topical antibiotics on pressure ulcers and the guidelines issued by the expert group on pressure ulcers stated that the use of topical antibiotics on infected pressure ulcers was generally not recommended, unless the wound was infected.

 

At the conclusion of the estate’s case in chief, the Hinds County Circuit Court, First Judicial District, granted motions for directed verdict by the rehabilitation facility, the woman’s primary physician at the rehabilitation facility, and the practice group.

 

The Court of Appeals of Mississippi affirmed. The court held that there was insufficient evidence that any alleged breach of care by the rehabilitation facility caused the woman’s death and that as a matter of law the estate failed to establish any breach of care by the primary physician.

 

There was insufficient evidence that any alleged breach of care by the rehabilitation facility caused the woman’s death. The woman’s expert in the field of nursing was not competent or qualified to testify as to issues of medical causation. The estate’s causation expert, the expert geriatrician, testified that issues related to the woman’s dehydration were resolved when the woman was transferred to the hospital. Consequently, there was no evidence that a breach related to dehydration caused the woman’s death. The assertions that the rehabilitation facility failed to timely notify physicians of changes in the woman’s condition were conclusory and unsupported by facts. The woman’s expert in the field of nursing failed to identify what changes the nursing expert thought that the rehabilitation facility should have brought to the attention of a doctor between the development of slough and the last five days of the woman’s care at the rehabilitation facility. There was also no evidence presented at trial that any notification during that period would have changed the outcome. There was no competent evidence in the record to link the unspecified, alleged breaches of care to the woman’s death. Accordingly, the rehabilitation facility was entitled to judgment as a matter of law and the trial court properly granted its motion for a directed verdict.

 

As a matter of law, the estate failed to establish any breach of care by the primary physician. The court found that the woman’s expert geriatrician’s testimony was illogical and inconsistent with the guidelines issued by the expert group on pressure ulcers. The guideline expressly addressed to the treatment of infected pressure ulcers. An infected wound was not a special situation warranting an exception to the guideline. The woman’s expert geriatrician’s testimony failed to establish a specific, legally sufficient standard of care or a violation of any standard of care because it was nothing more than the expert geriatrician’s own personal opinion about how the woman should have been treated. No evidence was presented at trial that the treatment ordered by the primary physician was below objectively ascertained minimally acceptable levels of practice by physicians nationwide. Because the estate failed to establish the standard of care or a breach thereof, the primary physician was entitled to judgment as a matter of law, and the trial court properly granted his motion for a directed verdict.

 

The Court of Appeals of Mississippi affirmed the trial court’s grant of the motions for a directed verdict by the rehabilitation facility, the primary physician, and the practice group.

 

See: Butler v. Chadwick Nursing & Rehab. Ctr., 2017 WL 3190593 (Miss. Ct. App., July 25, 2017) (not designated for publication).

 

See also Medical Law Perspectives Report: How Risky Is Going to the Hospital? The Dangers and Liabilities of Healthcare-Associated Infections

 

 

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