A death at Boston 's Children's reverberates

[NRSKarenRN, BSN, RN]

A death at Children's reverberates

State review finds system problems

By Anne Barnard, Globe Staff, Globe Columnist, 8/7/2001

http://www.boston.com/dailyglobe2/219/nation/A_death_at_Children_s_reverberates+.shtml

Taylor McCormack needed routine surgery to relieve pressure on her brain. It was Saturday night. A resident at Children's Hospital told her parents that the operating rooms were full, and ''the team'' had decided to postpone surgery until 8 a.m.

The McCormacks weren't happy, but decided to trust the hospital that had treated Taylor at birth, 13 months before. Surgeons there had implanted a tube to drain excess fluid from her skull. Now, that tube needed replacing, and Taylor's mother lay down by her bed to wait.

But, around 6:20 a.m., Taylor stopped breathing. Her mother ran into the hallway, shouting, ''She's blue!'' A doctor who had come to prepare her for surgery hit the emergency ''code'' button instead. A team rushed to Taylor's side, but she suffered brain damage. She died six days later.

The death of Taylor McCormack offers a window into the difficult, often painful process of finding the causes of medical tragedies. No one can say for sure whether Taylor would have lived had things been done differently. But in a report completed last week, state public health officials found systemic problems that may have contributed to her death, some of which were also noted in an internal hospital review.

Taylor should have spent the night in an intensive care unit for closer monitoring, the officials concluded in the report, which Taylor's father provided to the Globe. Test results showing critically low carbon dioxide in her blood, a sign of breathing trouble, were not written that night on her chart.

And the senior physician in charge of her care, Dr. Craig van Horne, forgot that his pager was set to ''vibrate'' and fell asleep on his couch. He slept through several pages, leaving two neurosurgery residents - ''the team'' - to call the shots on their own.

Taylor's death was ''something that should not have occurred,'' said Nancy Ridley, who oversees hospitals for the Department of Public Health.

"In hindsight, the case required more rapid and intensive care,'' wrote a physician who reviewed the case for the report. ''The resident staff acted as their best judgment indicated,'' the physician added, noting that the residents should have tried to contact another attending doctor for advice. ''The residents should not have managed this case alone.''

To public health officials, the case is a classic example of how systems, not individuals, are mainly responsible for hospital errors, which a 1999 federal report blamed for 98,000 deaths a year. Taking the focus off individuals, they believe, encourages doctors to be honest about mistakes.

At the same time, talking about systems does not capture how the death has devastated the people involved. Since Taylor died Oct. 6, her father, John McCormack, a state trooper from Pembroke, has spent much of his time relentlessly seeking to hold Children's Hospital accountable.''I don't want this happening to another child or another family,'' said McCormack who is considering a lawsuit against the hospital.

McCormack has filed complaints with the state medical board against Dr. Tien Nguyen, the fifth-year resident who examined Taylor; Dr. Adel Malek, the chief resident who advised Nguyen by phone; and van Horne, an attending neurosurgeon at Brigham and Women's Hospital who was covering Children's that night.

In letters to the board, the three said Taylor received appropriate care and was stable until her condition suddenly deteriorated.

The death has sparked policy changes, and soul-searching, at Children's Hospital, which was named the nation's top pediatric hospital for the 12th straight year by U.S. News & World Report and has been a leader in the movement to prevent errors in Massachusetts. People involved were ''traumatized,'' Ridley said.

''They're very shook up,'' Ridley said. ''They're just beside themselves that this happened.''

According to John McCormack, Dr. Mark Proctor, who was called in to operate on Taylor after her respiratory arrest, told him and his wife, ''Children's Hospital failed you and they have to change their policies and procedures.''

Dr. Adre Duplessis, who cared for Taylor while she was in a coma, asked McCormack for a picture of the brown-eyed girl, who had just learned how to sing ''Bye Bye Bye'' along with 'NSync. Duplessis has the picture on his office wall, his wife said in a brief phone interview.

Hospital officials and doctors, citing ongoing proceedings, declined to comment beyond a brief written statement, saying everyone involved is ''profoundly sorry that Taylor died while in our care.''

''While we do not believe the actions of any one individual or system are responsible for Taylor's death, we do want to learn from this tragic event and do everything possible to avoid such an event in the future,'' it said.

Nguyen and van Horne did not respond to e-mails, telephone messages, and faxes. Malek declined to comment for this story.

The hospital plans changes in policies relating to communication between doctors, operating room scheduling, the settings of monitor alarms, and resident orientation, the report says. The hospital may file a response to the report up to Aug. 13.

It was the most glaring medical errors that first drew media attention, such as the death of Boston Globe columnist Betsy Lehman from an overdose of chemotherapy drugs at the Dana-Farber Cancer Institute in 1994, or the removal of the wrong kidney from a patient at Quincy Hospital in 1996. But the vast majority of preventable deaths in hospitals come in more complex situations, as doctors and nurses make multiple decisions ''in the heat of battle,'' Ridley said.

In such cases, it's hard even to know what deaths are preventable, researchers argued in a study published last month that challenged the 1998 Institute of Medicine report, saying it overestimated how many deaths resulted directly from errors.

For McCormack, there's only one error that matters: his decision not to question the postponement of Taylor's surgery.

With his buzz cut, receding hairline, and Ray-Bans, he looks something like a stockier Bruce Willis. During an interview, he turned red, and his eyes filled with tears. ''Sometimes,'' he said, ''I blame myself that I let her down.''

Taylor was born Aug. 23, 1999. She had hydrocephalus, a condition in which excess fluid presses against the brain and can cause mental retardation if not treated. Annually, around 10,000 children have shunts implanted to drain the fluid into the abdomen or elsewhere. They can usually live normal lives, but parents must be vigilant for blockages that can happen as the children grow.

Family videos show Taylor grinning in the arms of her brothers, ages 4 and 8. ''Where's my pretty girl?'' her mother croons behind the camera as Taylor chews on her fists. By her first birthday, she is grabbing McCormack's baseball cap and shouting, ''Dad-DEE,'' or propelling herself across the floor in a sitting position, her patented ''scoot.''

On Saturday, Sept. 30, 2000, her parents believed her vomiting and lethargy were signs of a shunt blockage. They say Nguyen, after first discouraging them on the phone, said they could bring her in. They arrived around 7:15 p.m.

Taylor was scheduled for surgery that night. But sometime after 10 p.m., Nguyen told them she had been ''bumped'' to the morning. There were four more urgent cases ahead of her, he said.

Blood tests were taken that later showed the critical carbon dioxide levels. It's unclear whether the lab failed to report them, or if bedside staff failed to note them.

Taylor was taken to Nine North, a neuroscience floor. Nurses took her vital signs at 12:40 a.m. and 4 a.m., not frequently enough, according to the DPH reviewer. She was on a cardiac monitor, but in the ICU, Ridley said, more complex monitoring might have caught her decline.

After Taylor became comatose and was sent to the ICU, her father railed against the hospital, once even threatening to kill the doctors and prompting a call to security. Proctor, who operated on the baby, held a staff meeting ''to get to the bottom of it,'' McCormack said another doctor told him.

Finally, DuPlessis told the family Taylor would never recover. They unhooked her respirator, and three hours later, she died. McCormack walked her body to the hospital morgue.

Her brother Stephen has a plan, McCormack said. ''He said, `Daddy, I'm going to climb up to heaven, put a Band-Aid on Taylor's head and bring her back.'''

Anne Barnard can be reached at [email protected].

This story ran on page A1 of the Boston Globe on 8/7/2001.

[nurs4kids]

This is very sad and scary. Rarely do we admit a shunt malfunction that late at night that doesn't wait until the am for surgery. The neurosurgeon's do typically check their pressure in the ER and then they are normally sent to the floor, not ICU. We monitor them with nothing more than an oximeter and q4 vitals. The one thing we all know is that these patients can go from stable to crashed without a moments notice. Even upon crashing, these kids are usually very responsive to treatment. I suspect they'll find this child had some other underlying problem.