1/7/25, 84 year old female, full code, living independently, was found to have a perforation of stercoral ulcer of the sigmoid colon with fecal peritonitis and over 1,000 ml of pus and underwent a sigmoid colectomy with descending colostomy. After being extubated, the patient initially recovered from the surgery well and came out with her abdomen closed. A few hours later, on 1/9, she was not making urine and had ph and lactate indicating sepsis causing her to be re-intubated. When her daughter arrived 4 hours later, she noted her mother’s OG tube was coiled in her mouth with no output in the canister. She could see it was full of green/brown GI contents. She informed the nurse and she uncoiled it and hooked it to suction. It immediately filled an entire suction canister and almost a second canister.
She was extubated on 1/11. CT taken early on 1/12 showed a massive aspiration within the left bronchus extending into the left lower lobe. The left bronchus was completely filled with debris. Over 7 hours after the CT scan results were posted, the patient’s daughter, an RT, noted the CT results regarding the aspiration. When she arrived at the hospital, the daughter observed her mother struggling to breathe, her face and neck were red, she was tachypneic, and using accessory muscles. She immediately brought the results of CT and her mother’s appearance to the attention of the nursing staff who appeared to be unaware of either. The daughter requested a bronchoscopy be performed but the nurse resisted. Ultimately, a doctor was called and agreed that a bronchoscopy was warranted and once initiated, a foreign body in the left mainstem bronchus was encountered, blocking the take off to the LLL and LUL. It appeared to be clear plastic, and was occluding most of the segmental airways. He was unable to use suction to remove.it. He had to wait for the large bronchoscopy cart with the rigid bronch tube and additional forceps to continue with the procedure. He was able to retrieve the object which was a piece of hard plastic, 1 cm x 0.5 cm x 0.5 cm. It was not determined how the piece of plastic got in her left bronchus.
She was extubated on 1/14. The patient’s Bipap went dry and no mucolytic was ever started. She developed a mucus plug and went into respiratory distress causing her to be re-intubated on 1/19 and requiring another bronchoscopy which resulted in further aspirations. It was noted on 1/23 that they would be completing Abx course tomorrow for “aspiration pneumonia and will wean steroids for pulmonary inflammation d/t foreign body.”
The patient’s colostomy was placed very close the abdominal incision. The ostomy was also “concave” making it harder to dress. From post op day one, her family observed, the contents of her ostomy contacting her fresh surgical incision. The patient’s drain began to display a purulent thick tan discharge from her incision. The wound began to “hiss” and multiple staples had to be removed leaving her with an open abdominal wound. This coincided with a WBC count becoming increasingly elevated. Scan on 1/18 confirmed a significantly infected stoma. Wound care ultimately found dressing that was better suited to the concave stoma, but it was not always available to nursing staff. Wound care indicated they would only leave a small amount of the dressing at a time because they did not want it to get into the wrong hands.
Despite a hiatal hernia and not tolerating NGT, she was not started on TPN until the 12th day of hospitalization. She lost 17 pounds in 17 days and became very weak.
She developed a necrotic thumb due to art line that was not secure post-surgery. When transferred from ICU to step down on 1/25, she was noted to have a decubitus on her coccyx.
Family put in for transfer to Sutter in Sacramento because of the poor care they observed at the hospital and because daughter worked at Sutter. The transfer was approved by Sutter but local doctor became visibly upset about the transfer stating it was dangerous because she was on Bipap. He then asked patient who, according to the family was confused, and she stated she did not want want to go in an ambulance to Sacramento.
Family felt pressured into DNR status even though their mother had an existing full code. The Patient was capable of making that decision but her consent was not obtained. The doctor stated to the family “Don’t even ask her what she wants, you and your sisters just need to make the decision for her to let her go.” Following DNR designation, family observed care decline. They sought to change the status from DNR, but would met with resistance. The night she died, her daughter was in the room and observed her mother having a panic attack that caused the RRT to come to her room because of her elevated BP and HR but the nurse put her arm up and stated that the patient was a DNR and the RRT stood down. The family was then pressured to start comfort care which was chosen over seeing their mother suffering and afraid.
Patient died 1/30/25 cause of death: acute hypoxic respiratory failure, recurrent aspiration pneumonia due to large hiatal hernia, perforated sigmoid colon s/p Sigmoid colectomy with descending colostomy
Files:
Q: Was there any plastic seen on CT imaging of the lungs?
A: —
Q: Was the plastic sent to pathology for possible identification?
A: —
Q: The patient was ambulatory prior to becoming ill, but a stercoral ulcer is a pretty significant complication, typically of constipation, and I wonder if she had sought care for the constipation or abdominal pain prior?
A: —
Do you believe there might have been medical error?
The plastic debris in the airway could only have been introduced by health care provider.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This led to a cascade of events including reintubation, malnutrition, etc
What makes you a good expert for this case?
I routinely practice in the ICU as a cardiac critical care specialist
How often do you encounter cases similar to this one in your practice?
this is a common case to an icu
Do you believe there might have been medical error?
Foreign body lodged in bronchus. Poor ostomy placement Abdominal infection next to ostomy. Lack of nutrition for over one week. Pressuring family to make an otherwise functioning person a DNR.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Foreign body in bronchus ultimately led to hypoxia respiratory failure.
What makes you a good expert for this case?
I have reviewed over 60 cases over the past 12-13 years, many which involve negligence similar to this case.
How often do you encounter cases similar to this one in your practice?
In my practice it is exceedingly rare to come across cases that involve such obvious areas of negligence.
Do you believe there might have been medical error?
There was likely a mishap with regards to foreign body appearing in the lungs. I suspect it was from an attempted ng tube placement gone wrong(in other words it being placed initially in the airway rather than the esophagus.)— I would be curious to see the x-rays that were performed around January 9 and whether two placement was correct. Is there any evidence of plastic on the chest CT? It sounds like there was delaying and diagnosing the aspiration event… much of this case revolves around Daughter and medical staff interactions, which were clearly suboptimal… issues relating to the abdominal surgery are within reasonable complication list. I don’t like that there was a sacral decubitus ulcer and significant delay to beginning TPN. The infected thumb from arterial line also falls within possible complications for which there was likely consent.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Well there are many medical mishaps here the ones that concern the most are the decubitus ulcers and lack of nutrition from delay in placement of TPN. While the others are unfortunate, they don’t fall into the negligent category, more likely, inexperienced physicians and very poor communication skills
What makes you a good expert for this case?
Unfortunately, caring patients in the ICU, We see these kinds of complications all of the time. This sounds like a disgruntled daughter and while she may give poor reviews to this hospital, the only errors are the ones I stated above…
How often do you encounter cases similar to this one in your practice?
I have seen several poor nasogastric tube placements and yes, sometimes they lead to aspiration pneumonia.. usually family members are unaware of these events, especially since NGT placement, no longer requires family consent Sometimes there can be delay in initiation of TPN and there may be very good reasons for that With regard to the decubitus ulcer, this is unfortunate but did not lead to the respiratory failure here
Do you believe there might have been medical error?
(1) There is no information about the plastic object that was found in her bronchus. If it were known to be a medical device or a broken part of a medical device that is used in the mouth then I would conclude that there is a medical error, but it's possible that this is something the patient put in her own mouth. 2) Feeding tubes very commonly become dislodged in hospitalized patients. It is a known risk. That is not a medical error unless there is evidence of some breach in practice. 3) Aspiration events are known risks of hospitalization, surgery, and tube feeding, particularly in the elderly.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Without an obvious medical error I cannot conclude that there was causation.
What makes you a good expert for this case?
Infectious diseases practitioner, also many years prior experience in hospital medicine.
How often do you encounter cases similar to this one in your practice?
I don't encounter cases like this.
Do you believe there might have been medical error?
The orogastric tube having been coiled in the patient's mouth and not draining gastric contents for an indeterminate amount of time is concerning. One should review the nursing notes and attending physicians notes to see if the orogastric tube was being examined and documentation of quantity out was being documented. This likely led to the pneumonia. The plastic piece might be a red herring, though I wonder if it was sent to pathology for possible identification. Certainly, though, if the plastic piece was a portion of the NG tube or a piece broken off during intubation, then that was unintended, but I wonder if vitals were being monitored and if patient was hypoxic. Could imaging have been done earlier to catch it earlier. The plastic piece might have been an unintentional error, but that may not be able to be proven at this point. What is concerning, however, is the responses to the patient's deteriorating situation, and how attentive the staff was to the patient's vital signs, physical exam, and imaging findings.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If staff were inadequately attentive to the patient (i.e. OG tube coiled in mouth and not draining appropriately, CT scan results not reviewed in a timely manner, bronchoscopy delayed), then these oversights and or delays in care may have contributed to the worsening situation and demise of this patient.
What makes you a good expert for this case?
I am not a good expert for this case as I have not practiced inpatient medicine since residency and graduated from residency in 2018. However, from the knowledge and experience I have, it certainly seems reasonable that this case be examined closely. I would recommend a hospitalist and also a Pulmonary/Critical care specialist.
How often do you encounter cases similar to this one in your practice?
As I practice outpatient medicine, this is not routine for me. However, I certainly have experience with older patients. I do recommend that the patient's primary care physician records be examined to see if the patient had sought treatment for constipation or abdominal pain prior to this episode occurring.
Do you believe there might have been medical error?
More information is needed about this case since multiple, scantly described events were brought up. I believe a full chart review is necessary to make an accurate determination. I am inclined to think that the plastic piece found in the airway could have been secondary to some form of medical error, but more details are required. It is possible this was aspirated at home or at any time during the hospitalization. It might be difficult to prove where it came from and even so, whether there was medical responsibility in the event. It could be impossible to determine whose responsibility it was to prevent it. Another instance in which there might be medical error was during the calling off of the RRT. DNR is not an indication to hold therapy. Was there an assessment of the cause of the RRT? Was the patient also DNI? Was she offered non-invasive ventilation? Finally, it is the patient or her surrogate who determines code status. If the family reversed the DNR and this was not followed, this would constitute a medical error. Physicians can recommend a DNR/DNI, but cannot impose it. The family should be questioned to determine whether this was the case. I am inclined to think that there was no significant errors in the following: - delay in TPN initiation (up to 14 days is acceptable) - Lack of mucolytics: not outcomes benefits with mucolytics - Infected wound (opinion better suited for a surgeon) - Transfer to another hospital. In general, we favor patient's autonomy. And transfer can be dangerous in acute respiratory failure without a clear advantage for such transfer, such as inability to provide needed care. However, I would investigate whether there was documentation of competency around the time the patient declined transfer. Also, investigate the discrepancy about asking the patient about transfer, but asking the family about code status. Was there a change in mental status that precluded the patient from making decisions about her code status?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the points I described above (plastic aspiration, calling off the RRT, rejection of DNR reversal) are true, there could be causation. However, more information is needed
What makes you a good expert for this case?
I am an experienced surgical critical care physician who deals with similar cases on a daily basis. I have led many surgical critical care quality improvement initiatives. I trained and work in reputable institutions (Mayo Clinic, NYU, VA) and have an academic appointment teaching surgical critical care to students and residents
How often do you encounter cases similar to this one in your practice?
On a daily basis. I work in surgical intensive care
Do you believe there might have been medical error?
An intra-abdominal sepsis from a bowel perforation on an elderly patients carries a high risk for mortality upfront. 1liter of pus is a major source of inflammation of the whole body. The plastic found in her left lung was causing the pneumonia most likely. Even with broad spectrum antibiotics, these patients may not do well.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Doctors did the surgery, cleaned out, washed out, broad spectrum ATBs. OG tube was clipped but then released and draining. This likely was ordered by the surgeons, clipping the OG may have a good reason otherwise stated in the chart. A review of the physician order of the OG tube and whether the nurse follow that order is an open question.
What makes you a good expert for this case?
I am an attending physician in infectious diseases for over 15 years in academic setting.
How often do you encounter cases similar to this one in your practice?
I see these cases every month in my practice in the hospital (tertiary medical center).
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