Disclaimer: The case described below is entirely fictional, and any resemblance to real situations is only coincidental. This exercise aims to allow you to see the example of a report that a client will receive after requesting an “Initial Review.”
Final Report – Initial Review:
Dear Parents (Mrs. and Mr. Smith), Thank You for allowing me to assist you with reviewing the quality of medical care provided to your child in Hospital X. Please read this review carefully and write down any questions you may have. We will discuss your concerns and questions during our follow-up phone conversation. I will schedule it within the next week if you are available.
Summary of the case:
The patient (baby boy – John Smith) was born by urgent cesarean section on 10/21/2022.
Maternal history: Mother (Mary Smith) is a 28-year-old, generally healthy, white woman. She was receiving regular perinatal care during her pregnancy from her obstetrician (Doctor Z). Her prenatal labs included blood type O Rh positive, GBS test positive, RPR negative, and HepB antigen-s negative. Mary Smith presented in labor on 10/20 at 9 a.m. at 39 weeks of gestational age and was admitted to a labor room. The initial phase of her delivery was unremarkable. On 10/21, around 9 a.m., she started having a lot of pain in her lower abdomen. She delivered a baby boy by cesarean section 2 hours later.
Birth Hx: Baby was born by urgent C/S (due to decelerations for the last 2 hours). Full term newborn, with no obvious congenital anomalies. Birth Weight: 3.5 kg. Apgar scores: 1 at 1 minute, 0 at 5 minutes, 0 at 10 minutes, 1 at 15 minutes, 2 at 20 minutes, 5 at 30 minutes. Subsequently, the baby was transferred to an Intermediate care nursery for further care.
Resuscitation in Operating Room: Baby received Positive Pressure Ventilation – PPV (artificial breathing) from 3 minutes of life, chest compressions from 5 minutes, and 3 doses of epinephrine via ET tube placed only at 20 minutes of life.
Hospitalization course: The patient was placed on a ventilator and was treated with antibiotics and fluids. X-ray done two hours later showed pneumothorax. The chest tube was inserted. The pediatrician called a level 3 NICU at 8 hours of life, and the baby was transferred out 9 hours after the birth. The patient died the following day in level 3 NICU at University Center. The autopsy report from the university hospital is not available yet.
Statement regarding the standard of care:
Medical management did not meet standards of care. It led to a new disease or symptoms or worsened the existing condition. It resulted in physiological or anatomical impairment, disability or death, and unnecessary prolonged treatment, complications, or admissions.
List of deviations from the standard of care:
- There was only one person (nurse) available in the OR to initiate resuscitation efforts for the baby
- Delay in initiation of PPV – positive pressure ventilation
- Delay in initiation of chest compressions
- The pediatrician arrived only 12 minutes after the birth of the baby
- Intubation took place at 16 minutes of life after 3 attempts
- Epinephrine was administered 3 times via ET tube and not intravenously
- Delay in obtaining a chest X-ray
- Delay in diagnosing and treatment of pneumothorax
- There was a delay in calling the university center to transfer the patient
- There was a lack of awareness among the medical providers that the patient should have been diagnosed with HIE (Hypoxic Ischemic Ecephalopathy) and most likely qualified for specialized therapy such as whole body cooling or head cooling
- The pediatrician consulted a neonatologist by phone, but a neonatologist never came to the NICU to lead stabilization efforts for this baby
References:
- Textbook of Neonatal Resuscitation – 8th edition – American Academy of Pediatrics and American Heart Association, 2021
- Guidelines for Perinatal Care – 8th edition – American Academy of Pediatrics and American College of Obstetrician and Gynecologists, 2017