Hospital Fails to Follow Physician Orders

We represented the family of a man who died unnecessarily after respiratory failure at an Oregon hospital resulted in a brain injury.  The respiratory failure occurred because the hospital failed to follow physician orders to place the man’s “CPAP” (continuous positive airway pressure) machine on him.

Sleep Apnea/CPAP Machine

The man was diagnosed with severe obstructive sleep apnea, which occurs because the soft tissues of the throat relax and narrow, or completely collapse, during sleep.  This obstructive breathing results in cessation of breathing, also called apnea. Periods of apnea decrease oxygen levels in the blood and within minutes can cause major organ dysfunction and permanent brain damage.

CPAP machines are used to treat severe obstructive sleep apnea.  A CPAP machine increases blood oxygen by delivering a stream of compressed air, which keeps the airway open so that unobstructed breathing is possible.  This reduces or prevents periods of apnea.

The man had sleep studies that showed severe obstructive sleep apnea. He was prescribed a CPAP machine, and sleep studies with that machine in use showed that it was effective.

Later, for completely unrelated reasons, the man needed knee surgery.  Both the orthopedic surgeon and the primary care physician recognized the seriousness of the man’s sleep apnea, and his need for his CPAP machine while he would be in the hospital for the knee surgery.

Knee Surgery and Post-Surgical Events

The knee surgery went as planned.  The surgeon had the CPAP machine used throughout the surgery. Following surgery, the man was transferred to the post-anesthesia care unit, and after approximately one hour, was moved to the general hospital floor. The physician specifically ordered that the man’s CPAP machine be used.  The post-operative orders also required supplemental oxygen, and oxygen monitoring of the man following the surgery.

The CPAP machine was transferred with the man after surgery into his post-surgical hospital room, and was seen by family members on the  bedside stand.

While in his hospital room, the man was positioned on his back to accommodate his right leg being elevated.  In addition to being positioned on his back, he received several central-nervous system depressant medications (narcotics, antiemetics, antianxiolytics).  These central-nervous system depressants have known effects of causing depressed respiratory function. Visitors to his hospital room heard the man having “snoring respirations.”   Family members twice specifically requested that hospital nurses place him on his CPAP machine. The nursing staff did not comply with the family’s repeated request, or with the doctor’s specific written orders.

For unexplained reasons, the man’s supplemental oxygen was stopped.  The hospital nursing notes reflect the man was sleeping and “light snoring” was heard at 9:00 p.m., and again “sleeping” and “light snoring” was charted at 9:30 p.m.  At 9:50 p.m., he was described as being found without a pulse and in “resp (respiratory) distress with visual agonal breathing.” The term “agonal” breathing describes when a person takes only  3-4 breaths per minute. This is an extremely serious medical sign indicating that the patient is not getting enough oxygen.

A code was called at 9:50 p.m., and efforts were taken to save the man’s life.

Nursing staff did not chart  that they checked the man’s oxygen saturation levels at any time during the nine hours leading up to the code being called.

Following resuscitation, the  doctors diagnosed the man as having suffered severe anoxic encephalopathy (brain damage from lack of oxygen), and transport was arranged to a larger hospital for further testing.  At the second hospital, physicians noted that the man had “suffered profound anoxic brain injury. This is somewhat unusual, given the duration of poor perfusion and also the fact that this was a primary respiratory event rather than cardiac.”

As is often true in a hospital systems failure case, the hospital failed to follow multiple safety procedures.  Supplemental oxygen was ordered by the physicians, but discontinued by the hospital without physician approval. Use of the CPAP machine was ordered by the physicians, but those orders were not followed by the hospital.  Oxygen saturation levels were ordered to be monitored on a regular basis after the surgery, but the hospital went nine hours without doing the required monitoring, up until the man coded.

Human Costs To Hospital System Failures

The man was a retired railroad employee, with thirty years of service, primarily as a switchman and a brakeman.  He was enjoying an active retirement of fishing, golfing, and camping with friends and family. He wanted to be able to be more active with less pain, which was the reason he elected to undergo knee replacement surgery.

He had a love for life and he made the lives of those around him richer.  He and his wife camped and fished together. They were close with other couples in the community and socialized frequently.  He and his male friends enjoyed working together and shared home improvement projects. They golfed and frequently had lunch together.  He had a fantastic sense of humor, and had a way of encouraging others to be more active and to celebrate each day.

He was the father of two children, and the grandfather to many more.  He was a solid, reliable man. He would do anything he could to help his friends and family.  Many of his family members and friends were able to visit him in the hospital before he coded and before his death, but many more did not get this opportunity.  He is greatly missed by all.

On the financial side, after his unnecessary and preventable premature death, his family lost a substantial amount of pension benefits.  There were also substantial medical bills for the post-coding care. His widow lost the value of the essential services he provided to her and their household. He was an attentive husband and helped with daily chores, meal preparation, laundry, and cleaning.  He was capable of performing many household tasks that many others hire out. If a household appliance broke or if the roof needed repair, he was the person who would fix it.

Sometimes people do not stop to think about the economic value of all of those household contributions.  There are experts who analyze the value of those services. That loss alone, over the remainder of the man’s expected lifetime if he had not been prematurely killed, was in the moderate six figures.

Concluding Thoughts

Most hospital system failure cases are vigorously fought, and require that a case be filed and litigated in the court system.  This case was unusual, in that the hospital’s risk management department and legal team were willing to negotiate with Lara Johnson before a court case was filed, and the case was settled for a confidential amount.