This case involves a newborn who is being observed and evaluated post-delivery. Child was born on December 30, 2023. This was a vaginal delivery with vacuum assist. There are no notations of any significant complications during the delivery. Apgar scores were 7/8. Mother's GBS and vaginitis swabs were negative. Delivery was 37 weeks and 5 days. Birth weight was 6lb and 8 oz.
On Dec 31, there are multiple documented instances by nursing concerning a new onset of grunting and nasal flaring with retractions. O2 saturations did vary between 88 and 95% during the day. The following morning around 11am, another episode of grunting and flaring happens on the day of potential discharge. O2 saturations are noted to be 97%, however the nurses have concern and call the neonatal provider.
The provider instructs the nursing staff to DC home later in the day pending any further grunting episodes. They also encourage skin contact. No radiology was ordered and no further testing was ordered.
I have attached a screenshot of this assessment and notation that was made in the record.
Additionally, no further assessments are made by the nursing staff nor a follow-up done by the provider to address the respiratory concerns.
The discharge instructions report that the mother and child left the building at approximately 4:30 p.m. on the 1st. D/C vitals (that appears to have been done multiple hours prior) were temp 99.0, HR 146, RR of 56 in the blood pressure of 58/29. O2 saturation 96%.
Vital sign charting attached as screenshot.
There is no full assessment performed by the nursing staff nor a detailed physical exam. Provider made no further documentation or follow up of respiratory issues. since the 11am notification.
The mother was concerned about the breathing abnormalities when being discharged, but says was reassured by staff that it was "normal". The following morning, after an early morning feeding, the child was found passed away in their crib. An autopsy was performed soon after in which the resulted in extensive acute bronchopneumonia with a left lung culture positive for streptococcus pneumoniae with frothy secretions in the major bronchi.
We have consulted with a neonatal nurse who was able to give an opinion concerning the nursing staff and their documentation/lack of actions.
We are concerned about the standard of care with the neonate provider. More aggressive diagnostic testing? Follow up/reassessment prior to discharge based on the nursing documentation of respiratory symptoms? Especially since the notification of ongoing symptoms was made just prior to D/C.
Thank you in advance.
Files:
Q: When was GBS screening done in pregnancy? Were there any risk factors regarding early onset sepsis such as length of rupture of membranes in hours, maternal fever, or other pregnancies/newborns with GBS?
A: Per the PC, the week prior to delivery. No known risk factors.
Q: Are your sure that the autopsy showed streptococcus pneumoniae (very unusual) and not group B streptococcus (streptococcus agalactiae)?
A: Yes, we have a copy of the autopsy report from the examiners office.
Q: 1.) Duration of rupture of membranes?
A: —
Q: 2.)Did mother receive intraparum antibiotics? 3.) Did infant have any blood work (CBC, blood culture, CRP?)
A: —
Do you believe there might have been medical error?
As an experienced neonatologist of >40 years now, one of the first things I teach all health care providers is to take any symptomology in the newborn in the first 24-48 hours, very seriously. Respiratory symptoms have to assessed carefully and a minimal work up that includes a rule out sepsis with Chest Xray and blood work (CBC, culture) must be done. If symptoms persist past a couple of hours or any of the blood work or Xray shows any abnormality, antibiotics must be started. This was gross negligence.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I lecture on the topic of Respiratory distress in the immediate newborn and I emphasize that infection must be considered and ruled out always. This is because the consequences of missing infection in the newborn and not starting antibiotics promptly when indicated can lead to dire consequences, as in this case.
What makes you a good expert for this case?
I am a very experienced neonatologist with a stellar career as a fcaulty member in top institutions such as UCSF, UCLA and UIC. I was the Head of the division of neonatology at Harbor-UCLA and Head of the Children's hospital at UIC. My reputation is exemplary, wide and very well known. I have served as an expert on medico-legal cases for several years now.
How often do you encounter cases similar to this one in your practice?
Such cases are encountered quite frequently. Cases of respiratory distress in the immediate newborn period with a work up of rule out sepsis is common (1-2 per 100 live births).
Do you believe there might have been medical error?
It would have been prudent to have a chest radiograph done for those symptoms and desaturations. The symptoms were intermittent. The newborn was discharged from the hospital after how many hours of life? Most early onset sepsis happens first 24-36 hours of life. I can argue more likely than not that if the chest radiograph was done that it was not normal. I can argue that if the family had concerns that the standard of care would be to observe the newborn for a minimum of continuous pulse oximetry to insure newborn well-being.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Early onset infection more likely than not identified with chest radiograph and CBC at 12-24 hours of life. However, there were no risk factors for GBS infection. I would’ve anticipated that the newborn symptoms would have been more persistent prior to discharge
What makes you a good expert for this case?
Over 40 years' experience as a neonatologist. Expert in the field of malpractice for over 20 years
How often do you encounter cases similar to this one in your practice?
Cases of early onset sepsis is routine in neonatal clinical medicine
Do you believe there might have been medical error?
As a neonatologist and pediatrician, both a bedside nurse and a parent expressing concern warrants re-assessment of the patient with a hands on physical examination and review of all of the vital signs and charted metrics. The above statement that these actions were not taken breaches standard of care in clinical practice. There are also opportunities for potential improvement in both the assessment and management of this neonate, which requires more in depth review of the maternal prenatal records, labor and delivery course, and postpartum neonatal course in addition to the items shared above.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Neonatal pneumonia has specific diagnostic findings that make the lack of appropriate physical examination and serial reassessments, along with the abnormal vital signs documented throughout the baby's stay as listed above very concerning for causation. Review of the standard neonatal discharge testing and findings would help to complete the clinical picture of opportunities for improvement and differentiate the causal versus correlative contributing factors to this baby's mortality.
What makes you a good expert for this case?
My passion is to utilize my medical education, scientific and clinical training, and healthcare expertise along with clear, concise, and accurate verbal and written communication and interpersonal skills to ensure standard of care for patient safety and quality outcomes. BOARD CERTIFICATIONS and KEY AREAS OF EXPERTISE: • Double board certified by the American Board of Pediatrics in both Pediatrics and Neonatal-Perinatal Medicine. o Enrolled in ongoing maintenance of certification and continuing medical education didactics for both Pediatrics and Neonatology board certifications. • In addition to subspecialty-focused work in neonatology, pediatrics, obstetrics, gynecology, and perinatology, maintain adult and geriatric medical knowledge through interdepartmental hospital and managed care collaborations- including with the emergency, intensive care, medical-surgical, and orthopaedic departments, as well as military and community healthcare volunteer work. • Physician-leader in both clinical and non-clinical work environments with additional certifications and administrative appointments onto numerous organization and medical staff committees, including the following: o pharmacotherapy, biotechnology, and device development o medical writing, publications, and policy statements o quality improvement and performance review case and peer reviews o credentialing o utilization management o electronic medical record creation and development o medical ethics • Medical director for a national health insurance company with managed care organizational knowledge to establish and enforce policies and guidelines, perform reviews, and ensure patient safety. • Expert medical case, records, and peer performance reviewer able to critically think and write in an impartial and unbiased manner. • Well-versed in telemedicine development, implementation, and system growth as former corporate national medical director of telehealth. • Editor and reviewer of international medical publications and journals. • Educator, presenter, and public speaker at research platforms, science academies, healthcare organization meetings, biotechnology conferences, didactic sessions, and executive leadership forums.
How often do you encounter cases similar to this one in your practice?
This type of case is commonly encountered in my work as a double board certified neonatologist and pediatrician working in both the neonatal intensive care unit (NICU) and newborn nursery.
Do you believe there might have been medical error?
Grunting and retraction are not normal in a well newborn. Why many neonates may have transient tachypnea of the newborn, this typically resolved quickly. The vital signs do not show evidence of tachypnea. It appears further investigation was needed, including physician examination and possible additional studies such as CBC and differential, chest x ray, blood gas, snd even blood culture with initiation of antibiotics despite negative maternal GBS screening.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Lack of exam and laboratory, x-ray studies and initiation of antibiotics in an infant with persistent grunting is problematic. Findings at autopsy demonstrated infection. This might have been prevented with early workup and evaluation of possible sepsis in a symptomatic neonate.
What makes you a good expert for this case?
I am a board certified neonatologist with over 40 years of experience.
How often do you encounter cases similar to this one in your practice?
Now Emeritus status, but saw this type of presentation not infrequently.
Do you believe there might have been medical error?
Based on the case details provided, there may have been a lapse in the standard of care that could constitute a medical error. The newborn exhibited concerning respiratory symptoms, such as grunting, nasal flaring, and retractions, which were documented multiple times by nursing staff. These signs and fluctuating oxygen saturations warranted further evaluation and potentially more aggressive diagnostic testing to rule out any underlying pathology, mainly since these symptoms persisted into the morning of discharge. The decision to discharge the newborn without a complete reassessment or follow-up by the provider is concerning. While the newborn's oxygen saturation was documented as 97% at discharge, the clinical presentation suggested respiratory distress that should have prompted additional investigations, such as a chest X-ray, to assess for pneumonia or other respiratory conditions. The lack of a comprehensive physical examination and provider documentation following the concern raised by the nursing staff may have contributed to the tragic outcome. The absence of adequate follow-up and the reassurance provided to the mother despite her concerns about the baby's breathing abnormalities further raises questions about whether the provider fully addressed the clinical risks presented. Given that the child passed away the following morning with autopsy findings of acute bronchopneumonia and a positive culture for Streptococcus pneumoniae, it is plausible that earlier intervention and more thorough evaluation might have identified the severity of the respiratory condition, potentially altering the outcome. In conclusion, a more comprehensive assessment, additional diagnostic testing, and closer follow-up before discharge could have prevented this outcome. The failure to address the respiratory symptoms more aggressively likely reflects a deviation from the expected standard of care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is a strong indication of causation in this case. The nursing staff repeatedly documented the newborn's respiratory symptoms (grunting, nasal flaring, retractions) and flagged them as concerning. These symptoms and fluctuating oxygen saturations strongly suggest respiratory distress that may have been linked to an underlying infection, such as pneumonia. The autopsy findings confirmed acute bronchopneumonia with a positive culture for Streptococcus pneumoniae, which directly explains the newborn's respiratory symptoms and subsequent death. The pneumonia was likely the cause of the noted breathing abnormalities but was not thoroughly investigated before discharge. The failure to pursue additional diagnostic tests (e.g., chest X-ray, blood tests) or reassessment before discharge, despite the ongoing respiratory concerns, likely allowed a treatable condition to go unrecognized. This oversight contributed directly to the outcome, as the infection progressed without appropriate intervention. In conclusion, the lack of appropriate diagnostic evaluation, follow-up, and consideration of the severity of the respiratory symptoms contributed to the child's death, establishing a likely causal link between the medical oversights and the fatal outcome.
What makes you a good expert for this case?
I am well-suited to provide an expert opinion on this case due to my 15 years of experience working in a level 3 academic neonatal center, where I have been directly involved in the care of critically ill newborns. In this setting, I collaborate with residents, fellows, and nurse practitioners, which has given me a comprehensive understanding of the complexities involved in neonatal care, particularly in managing respiratory distress, infections, and other acute conditions. Additionally, my academic role allows me to stay updated with the latest research and best practices in neonatology, reinforcing my capacity to assess the standard of care and identify potential gaps in clinical management.
How often do you encounter cases similar to this one in your practice?
In my practice at a level 3 academic neonatal center, cases involving respiratory distress or signs of infection, like pneumonia, are relatively common. Neonates, especially those born at term or near term, can present with respiratory symptoms due to a variety of causes, including infections, transient tachypnea of the newborn, or other respiratory conditions. While not every case progresses to the severity seen in this example, I frequently encounter situations where a thorough evaluation and timely intervention are crucial in preventing complications. Respiratory distress in the newborn can be subtle and sometimes mistaken for normal post-delivery adaptation, making vigilant monitoring and prompt diagnostic testing (e.g., chest X-rays, blood work) essential. Given the complexity of neonatal care and the high risk of severe infections in this population, I encounter similar scenarios regularly, reinforcing the importance of detailed clinical assessments and careful follow-up.
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