46-year-old Woman Dies of Pulmonary Embolism Due to Untreated DVT

Type of Injury: Death

Type of Case: Medical Malpractice

Settlement Amount: $2,250,000

On June 17, 2010, F-46 was seen at John H. Stroger, Jr. Hospital of Cook County (“Stroger Hospital”) with altered mental status (AMS) secondary to hypernatremia, acute kidney injury, and diabetic ketoacidosis. Later, the plaintiff was transferred from the Emergency Department (ED) to the MICU.

Plaintiff was going to be discharged in the afternoon on June 21st. However, this was rescinded because Plaintiff continued to have uncontrolled blood sugar levels. Between approximately 3:02 p.m. and 3:06 p.m., a physical examination of Plaintiff performed by a resident (Dr. Chengat) revealed that Plaintiff was still complaining of left knee pain (from an earlier injury), but no evidence of any DVT is documented.

That at or before 5:30 p.m. to 5:42 p.m., Dr. Chengat, who was working a shift from 8:00 a.m. to 5:00 p.m., performed an end-of-shift examination of Plaintiff that revealed a “new finding,” namely, that, in the face of DVT prophylaxis (heparin, 5,000 units administered subcutaneously (SC) every 8 hours), Plaintiff was experiencing symptoms of an acute DVT in her left calf (increasing in size, tender to palpation, with increased warmth). Dr. Chengat testified that he diagnosed a DVT that he knew “something has to be done”.

That at or before 5:50 p.m., Dr. Chengat ordered, via electronic transmission (Cerner) to the pharmacy, a STAT dose of enoxaparin sodium (Lovenox), 150 mg, to treat a DVT and expected the medication would be administered by a nurse within 30-60 minutes thereafter (i.e., 6:20 p.m. to 6:50 p.m.). Also, Dr. Chengat ordered an “ASAP” order for the ultrasound of Plaintiff’s lower left extremity.

That at approximately 5:59 p.m., Elaine Jean-Francois, LPN checked to see if there was any order for Plaintiff and, at that time, saw that Dr. Chengat ordered a STAT dose of enoxaparin sodium (Lovenox) to treat a DVT and acknowledge the same.

Between 5:50 p.m. and 7:04 p.m. on June 21st, the inpatient staff of pharmacists at Stroger Hospital consisted of Mr. Abey Thuruthiyil, Ms. Eileen Penaflorida, and Mr. Harry Thakkar. The supervisor of the pharmacy, Eurica Baker, was not present throughout the shift(s) that day. That at approximately 7:04 p.m., Thuruthiyil, accepted/verified the STAT order for enoxaparin sodium (Lovenox). This medication had to be sent from the pharmacy to the floor because it was not available in the floor’s Pyxis Medication Delivery system.

Before 9:50 p.m. (and at no time thereafter), the STAT order for enoxaparin sodium (Lovenox) was never administered. Further, the “ASAP” order for the ultrasound of Plaintiff’s lower left extremity was never performed to ascertain the nature and extent of the extension of the DVT.

At approximately 9:50 p.m., Jean-Francois overheard from the hallway Plaintiff screaming “help, help, and help.” Plaintiff was found lying on her right-side on the bathroom floor of her room. Michelle was complaining of shortness of breath (“I can not breath.”). (Plaintiff was “alert, verbally responsive, oriented times 4. Person, time, place.” Plaintiff's skin was cold to touch, and she was sweating. Plaintiff lost consciousness approximately five (5) seconds after Plaintiff told Jean-Francois that she could not breathe.

At approximately 9:51 p.m., Dr. Gaurav Agrawal was called and arrived at Plaintiff’s room at 9:54 hours. According to the Resuscitation Critique (Nurses Report)), Plaintiff arrested at 9:55 p.m. Following a 30-minute resuscitation effort, at 10:26 p.m. Plaintiff was declared dead by Dr. Agrawal. Plaintiff’s cause of death was an acute pulmonary embolism caused by the DVT.

The sole next-of-kin at the time of the settlement was Plaintiff’s 74-year old mother.

The above summary is specific to a particular case and is not intended as a projected outcome on any other matter.