Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
A Massachusetts woman, age 43, presented to her physician’s office complaining of a throbbing headache that had worsened progressively over the previous 48 hours. She was seen by a covering physician to whom she reported symptoms of nausea, vomiting, and photophobia. She had a history of headaches, which she attributed to a previous ear surgery.
The covering physician treated the patient with pain and anti-nausea medications and told her to follow up with her regular primary care provider. The woman went home and fell asleep on her couch. She later died in her sleep. Autopsy findings indicated that the cause of death was bacterial meningitis.
The plaintiff claimed that the question of whether the defendant physician should have considered bacterial meningitis turned on the presence of nuchal rigidity (stiff neck). The defendant conceded that if he had noticed nuchal rigidity, he would have entertained bacterial meningitis in the differential diagnosis. He testified that the decedent was negative for nuchal rigidity but that he had not recorded that finding. The plaintiff presented witnesses who observed that the woman was unable to move her neck during the time of her illness.
Outcome
A $1.45 million settlement was reached.
Comment
This is a classic case of documentation failure. Clearly, not every detail of every exam can be documented in a busy practice, but when a diagnostic decision is made based upon a defining symptom, as it was in this case, then the presence or absence of the defining symptom must be documented. Here, nuchal rigidity is the factor that distinguishes a routine headache from a headache that may be related to bacterial meningitis. Testimony without a record to back it up when it relates to this crucial fact may well have made the difference between a defense and plaintiff’s verdict. —JP