P.O. Box 39341 ♦ Greensboro, NC 27438
(O) 877.211.7562 Ext. 1 ♦ (F) 239.206.4567
www.legalnurseusa.com
Medical Malpractice Screening
Attorney: Celia Fate, Esq.
Case: Audrey Hepburn
Summary:
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PMH: 41 yr. old white female with Diabetes related to Chronic Pancreatitis; on oral medication
for diabetes until March, then put on injectable med via Flexpen June 2011 when our records
end; Diverticulosis; Irritable Bowel Syndrome; Depression; Gall Bladder Removal;
Hysterectomy.
Social History: Smoker for 30 years; denies alcohol. Diabetes untreated for 2 months due to lack
of insurance and finances to pay for medications and supplies.
PCP records reveal frequent infections and an inability to afford her diabetic
medications/supplies.
8/14/12 Evening: Presented to General Hospital (GH) complaining of constant, unrelieved,
10/10 left flank pain since 4AM. Reported nausea, vomiting, and difficulty urinating; denied
diarrhea or difficulty breathing. Pelvic CT scan: left 4 mm kidney stone; Serum Glucose: 403
(very high; normal 70-110). Given 14 units of regular insulin. Discharged with pain medication
and insulin prescriptions. Instructed to get insulin filled at CVS for $20. No documentation
about ability to measure insulin dosage or if she had insulin syringes. Instructed to drink plenty
of fluids and follow up with Urologist 8/16/14. [HEP000400]
8/16/12 1:00AM Presented to GH for worsened left flank pain and continued difficulty
urinating. CT scan: left 3 mm stone with kidney and ureteral enlargement. Urinalysis consistent
with infection and +3 glucose per admitting physician. Lab values revealed extreme blood
sugar elevation (702) with multiple other abnormal values. WBC count normal at 5.2.
[HEP000401]
Ms. Hepburn admitted to an un-monitored bed. The History and Physical indicates her blood
sugar elevation would be treated by subcutaneous insulin and aggressive IV fluids. The Urology
consultation noted no signs of infection and she should pass the stone with fluid hydration and
an alpha blocking medication. [HEP000523]
The last Nursing Note 8/16/2014 1:00PM (before 6:45 am on 8/17 — big gap) detailed a
conversation with Ms. Hepburn re: tearfulness and financial inability to obtain her diabetic
medications, supplies and anti-depressant medications. [HEP000415]
8/17/12 6:45AM Ms. Hepburn called out to report difficulty breathing. Respirations labored
and elevated at 30/min with oxygen saturation 95% (prior oxygenation 100%). Right lung
fields sounded wet (fluid filled) per nurse's note. 6:56AM Findings reported to Nurse
Practitioner, orders received and initiated (no orders included). 6:59AM Ms. Hepburn again
called out that she could not breathe and asked for something to help her rest. [HEP000467]
6:59-7:05AM Nurse left room to get nasal cannula to apply oxygen at 2L/min and returned to
find Ms. Hepburn "breathing hard.” She slumped over, became unresponsive with agonal
respirations, and turned blue. Nurse ran to desk to call code blue when no help came on
shouting for rapid response. [HEP000469]
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Attorney Work Product
Audrey Hepburn – Medical Malpractice Screening
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7:06AM CPR initiated. 7:07 AM Code team arrived. Note stated "See code sheet for other
details"; code sheet not included in records reviewed. [HEP000470]
7:30AM Received into ICU: gasping despite the ventilator delivering 100% oxygen at 12
breaths/minute; unresponsive; low-grade fever 99.4, facial flushing, moist skin,
supraventricular tachycardia (very fast heart rate); cloudy urine with sediment draining from
catheter. Chest X-ray showed diffuse alveolar edema (excess fluid in lungs impairing gas
exchange). [HEP000472]
7:52-10:15AM Oxygenation worsened (88%) despite multiple ventilator changes (increasing
rate, support and pressure) as well as, administration of Lasix (diuretic to pull fluid from lungs)
and Adenosine to slow heart rate. Airways suctioned for thick white blood tinged secretions.
[HEP000476]
10:30AM Generalized seizure activity treated with Ativan lmg and 11:32 AM Cerebyx (antiepileptic) loading dose. [HEP000477]
11:38AM Paralytic medication, Norcuron 10 Gm administered. [HEP000479]
12:04PM 500 ml saline bolus administered per Dr. Smith's order for decreased blood pressure.
[HEP000480]
12:05PM Transferred to Local Medical Center (LMC) via ambulance with RN and Respiratory
Therapist. [HEP000481]
GH Discharge Summary noted profound metabolic acidosis correcting at time of transfer.
[HEP000490]
12:02-13:03PM En route to LMC, she received saline boluses and a pressor infusion for
continued very low blood pressure ranging. Her oxygenation ranged 83-93%. [HEP000482]
8/17/2012 On receipt to LMC: unresponsive, without fever, pulse 184, blood pressure 93/66,
respirations 24 and oxygenation 92% on ventilator. Her labs revealed profound metabolic
derangement and her urinalysis showed findings consistent with a urinary infection.
[HEP000491]
Despite recuperation of Ms. Hepburn's pulmonary, cardiac, and renal systems, she never
regained consciousness. The Neurologist explained to her family she had likely suffered an
anoxic brain injury and would likely never recover. [HEP000498]
9/5/2012 Ms. Hepburn was transferred to inpatient hospice for palliative care. [HEP000499]
Ms. Hepburn's death certificate listed anoxic brain injury as the cause of death. [HEP000510]
Strengths:
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Inability to afford medications is not willful non-compliance, but an inability to obtain
medications related to uncontrollable factors.
3/2011: Last prescription for diabetic medications from IM Associates
GH documentation does not support assessment of ability to obtain, prepare, or administer
insulin from a vial.
GH Urologist did not note symptoms of infection noted by the admitting physician.
Lack of documentation from 1 PM 8/16/2012 to 6:45 AM 8/17/2012 is concerning for lack of
observation by staff
Treatment of extreme blood sugar elevation and accompanying metabolic derangement
inconsistent with Standard of Care. If close management had been provided per the SOC, this
crisis may have been averted.
Inadequate nursing management at 6:45 — 6:59 — no use of oxygen or call to rapid response
then 2L oxygen too low; lengthy response time for code team to arrive
Dose of Norcuron was excessive and may have contributed to circulatory collapse during
transport to GH. Furthermore, documentation does not support need to administer a paralytic.
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Attorney Work Product
Audrey Hepburn – Medical Malpractice Screening
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Paralytics would be used for ARDS if the patient was intolerant of the vent changes or was
thrashing around consuming too much oxygen.
Prolonged low oxygenation and blood pressure could most definitely impair end organ (brain,
kidneys,) perfusion and cause or contribute to an anoxic brain injury.
Weaknesses:
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Pre-existing diabetes secondary to long history of pancreatitis
Multiple notations of non-compliance with medications and blood sugar monitoring
IM Associates records indicate no treatment after 11/8/2011
Alerts/Inconsistencies:
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Urologist appears to have overlooked or minimized signs of infection noted by admitting
physician.
No included documentation supports occlusion of breathing tube, which would have been a
high alert incident.
IM Associates records indicate no treatment after 11/8/2011. Did Ms. Hepburn stop seeking
medical treatment? Did she change doctors?
Missing Records:
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Pharmacy records from 9/15/2011-8/2012; may have been from a nearby CVS. GH ED notes
she get prescriptions filled at Rite Aid.
Diagnostics from 8/14/2014 and 8/16/2012 GM visit: Labs, CT scans, X-rays, Ultrasounds.
Nursing documentation (Flowsheets, Shift assessments, Medication Administration) from
4:10AM 8/16 admission 8/17 12:05PM.
CPR (Code Blue or Resuscitation) Record detailing vital signs, cardiac rhythm, interventions
after she slouched over (7:06AM), during the code and until ICU transfer at 7:30AM.
Critical Care Flowsheets detailing assessments, interventions, and responses from 7:30AM12:05PM.
Interdisciplinary Progress Notes detailing events leading to, surrounding and after loss of
consciousness requiring CPR, intubation and transfer to ICU.
Physician orders after leaving the ED.
Potential Defendants
IM Associates:
• Failure to prescribe medications or assist with securing at a reduced cost likely contributed to
her development of kidney stones, sepsis, and life threatening hyperglycemia. Primary care
records indicate she stopped diabetic medications because she was financially unable to
purchase testing strips and hypoglycemics. Poorly controlled diabetes has been found to
increase risk of kidney stones by nearly 60%.
GH:
• Admitting physician failed to treat extreme blood sugar elevation per the treatment standard,
which may have prevented her cardiopulmonary collapse. Close management of fluid status,
blood sugars, and serum electrolytes every 2-4 hours is essential to avoid overcorrection and
avoid complications.
• Admitting physician failed to recognize diabetic crisis evidenced by extreme elevation of blood
sugar, severe metabolic abnormalities, nausea, and vomiting.
• Urologist failed to recognize and alter treatment plan for partially obstructing kidney stone in
the presence of apparent urinary infection and visible signs of systemic stress.
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Attorney Work Product
Audrey Hepburn – Medical Malpractice Screening
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Nurse failed to recognize impending crisis at 6:45 am, as evidenced by shortness of breath,
rapid respirations, decreased oxygenation and anxiety; failure to call a Rapid Response in a
timely manner and administer oxygen;
Questionable failure of unit system to respond to emergency in patient room requiring nurse to
leave a critical situation.
Recommendations:
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There appear to have been multiple failures, which likely led to Ms. Hepburn's death.
Missing records need to be secured to better investigate apparent provider failures.
Consider expert evaluation by a Critical Care Intensivist and/or Endocrinologist of care
provided for extreme blood sugar elevation, metabolic derangement, and initial treatment of
cardiopulmonary collapse.
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