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Patient with breathing problems died after hospital discharge – $2,475,000 Verdict

Virginia Lawyers Weekly//September 22, 2014

Patient with breathing problems died after hospital discharge – $2,475,000 Verdict

Virginia Lawyers Weekly//September 22, 2014

The plaintiff proved to a nine-member jury that on Sept. 1, 2011, Virginia Hospital Center negligently discharged the decedent, Jill Decker, with an impaired respiratory status and low O2 levels. Decedent, age 78, was a patient at VHC for wrist surgery on an outpatient basis. Due to her poor respiratory status, she was not discharged from recovery to home but admitted to the floor for further observation and continued supplemental O2. Discharge criteria for the recovery area (PACU) required that the patient be weaned off supplemental oxygen and returned to her baseline oxygen saturation level of at least 95 percent on room air prior to discharge. Unable to safely wean the patient off supplemental oxygen and discharge her from the PACU, the anesthesiologist transferred her to the floor on supplemental oxygen with an order for continuous monitoring of her oxygen saturation levels.

On the floor, decedent was negligently evaluated by a Virginia Hospital Center nurse. The assigned nurse failed to review anesthesia records, which revealed that the patient’s baseline oxygen saturation level on admission to Virginia Hospital Center was 95 percent on room air. She failed to review PACU records, which revealed that the patient could not be weaned off supplemental oxygen. Two hours prior to discharge when the patient was weaned-off supplemental O2, the attending nurse failed to report the patient’s low oxygen saturation level of 88 percent to the attending physician. She also failed to appreciate that the patient’s last oxygen saturation level of 91 percent (on room air), which was recorded 45 minutes prior to discharge, was likely inflated due to the patient’s concomitant use of an incentive spirometer. Finally, she also failed to appreciate and report to the attending or any other physician the patient’s persistent cough, coarse breath sounds, labored speaking, poor color, agitation, confusion, memory issues and disorientation.

Busy with other priorities, decedent’s discharge was handed off to a “resource nurse.” The discharge nurse checked only two things prior to discharging the decedent at approximately 1:45 p.m. First, she verified there was a doctor’s order on file to discharge the patient. The fact that the doctor’s discharge order had been written at approximately 9:30 a.m., when the doctor could not possibly have known of the patient’s poor oxygen saturation readings, did not factor into the discharge nurse’s decision-making. Second, she verified the discharge meds. According to the discharging nurse, her informal look at the patient during the signing of the discharge paperwork, coupled with the fact that patient’s oxygen saturation level was above 90 percent, was sufficient to conclude that her respiratory status was appropriate for discharge.

Roughly 16 hours after decedent was discharged from Virginia Hospital Center, she was found dead in bed by her daughter. The plaintiff’s experts testified that the fall that fractured the decedent’s wrist also caused a pulmonary contusion. The pulmonary contusion caused bleeding in the lungs, which was the cause of decedent’s respiratory difficulties at Virginia Hospital Center, and ultimately the cause of her death. Autopsy slides of decedent’s lung, reviewed by plaintiff’s expert pathologist, established the bleed in the alveolar spaces on the lung. The plaintiff’s experts further testified that the standard of care required that the decedent be kept in the hospital with supplemental oxygen, rest and supportive care until the cause of her low oxygen saturation levels could be determined. According to the plaintiff’s experts, proper evaluation in the hospital should have included a chest X-ray, which would have disclosed the lung contusion. Supportive care in the hospital for two to three days would have allowed the pulmonary contusion to heal on its own, at which time the patient could be safely weaned off supplemental oxygen. Had the decedent received the proper treatment, she would be alive and well today.

Decedent was a retired freelance author in Vienna. Although 78 at the time of her death, she was very active, walking every day, gardening and writing short stories and books, several of which were published. She left surviving three adult children and many grandchildren with whom she was very close. The damage award was based exclusively on solace.


Type of action: Medical malpractice – hospital negligence – premature discharge
Injuries alleged: Wrongful death
Name of case: Decker v. Virginia Hospital Center
Court: Arlington Circuit Court
Case no: CL 13-861
Tried before: Jury
Judge: William T. Newman Jr.
Date: Aug. 8, 2014
Verdict or settlement: Verdict
Amount: $2,475,000
Attorneys for plaintiff: William E. Artz and Andrew J. Waghorn, Arlington
Attorneys for defendant: Richard Nagle and Heather Zaug, Fairfax

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