Leading Medical Hospital Misses Fatal Infection in 12 Year Old: An Infection, Unnoticed, Turns Unstoppable

(NY Times): On April 1, three nights after he was sent home from the emergency room, he died in the intensive care unit. The cause was severe septic shock brought on by the infection, hospital records say.

Yet nowhere along Rory’s journey, from boy with a bellyache on Thursday to gravely ill boy on Friday night, did anyone act on strong indications that he might be fighting for his life. Critical information gathered by his family doctor and during his first visit to NYU Langone was not used, was not at hand or was not viewed as important when decisions were made about his care, records show.

The Stauntons knew nothing of his weak vital signs or abnormal lab results.“Nobody said anything that night,” Ms. Staunton said. “None of you followed up the next day on that kid, and he’s at home, dying on the couch?”

Rory Staunton, 5 feet 9 inches tall and 169 pounds, was big for his age and a student of the world.

The challenge for physicians is recognizing an invasive infection, whether from Group A strep or other pathogens, before the cascading damage of sepsis has picked up too much speed. The consortium of New York hospitals has a goal of starting antibiotics within an hour of spotting sepsis in the emergency room, according to officials with the Greater New York Hospital Association’s Stop Sepsis program.

Relatives and a priest gathered bedside, talking of Irish football and tomfoolery and politics. Perhaps, one doctor whispered in a fleeting, hopeful aside, Rory might get away with losing his toes and nose. His skin blackened. He passed no urine. His blood would not clot. His heart had to be restarted twice. Three specialists who chronicled Rory’s decline on his intensive care chart each noted that on Thursday night, when he was sent home from the emergency room, he had a fever and significant signs of infection in his blood.

On Sunday night, Dr. Mayer Sagy, who had not seen Rory on his first visit to the hospital but spent the weekend struggling to keep him alive, told the Stauntons that the team had been unable to resuscitate him a third time.

“I said to him, ‘I brought him here to you the other night and you sent him home,’ ” Ms. Staunton said.

“He said, ‘You have every right to be angry.’ ”

“Above all,” Ms. Staunton said, “we know that Rory would want no other child to go through what he went through.”

Read More:

Rory Stanton’s Fight for Life (NY Times)

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Medical Documents in Sepsis Death

 About Sepsis

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