Malpractice Case: Be Aware When Follow-up Requires Extra Steps

Gordon T. Ownby

Disclosures

March 02, 2020

In a letter 3 days later to Dr P from a university newborn screening program confirming metabolic screening for the baby, the program coordinator went on to state that because the initial hemoglobin pattern after a transfusion is not interpretable, optional follow-up testing is available through the program. The letter explained that "1 cc of whole blood is required to do white blood cell DNA analysis to determine the presence/absence of hemoglobinopathies. Please let me know if you would like to complete this follow-up testing. There is no charge to complete this test."

Enclosed with the letter was a pamphlet titled "Why Does My Baby Need More Testing for Metabolic Diseases?" Another handout, titled "FAQs about Newborn Screening and Transfusion Follow-up," explained that after a transfusion of packed red blood cells, the hemoglobin test pattern is not valid because the donor's blood cells mask the hemoglobin results for the newborn. A fax cover sheet included a question about whether Dr P was interested in following up on the transfusion matter.

At the 1-week follow-up visit by the parents and baby, Dr P's examination and review of the baby's development were normal. Carnitine labs delivered the next day were mostly normal, and by 1 week later, carnitine tests were all within normal limits.

At the baby's 1-month visit, Dr P noted the patient's history of possible carnitine deficiency and his examination showed a normal baby. A few days later, Dr P received a fax advising him that the physician overseeing the carnitine issue had resolved the case as having no screenable metabolic condition.

Medscape Editor's Key Notes:

  • Some patient cases can evolve past a doctor's expertise. In these cases, clear communication with specialists is required.

  • If assistance in interpreting or following up on a test is offered, physicians should accept, even just to confirm their understanding of the situation.

  • Warnings about test results should be explored fully by physicians to avoid adverse patient outcomes and possible lawsuits.

Later that month, however, while being fed by her mother, the baby started coughing, turned blue, and stopped breathing. At the ER, the baby was noted to have pancytopenia with a white blood count of 1.1, hemoglobin of 1.5, and platelets of 7. She received packed red blood cells during transport to a specialized hospital, but intervention there failed to improve on her "incredibly poor prognosis." The baby died after the decision was made to remove her from CPR.

A subsequent lawsuit by the baby's parents alleged that given his knowledge of the intrauterine transfusions for anemia following alloimmunization, Dr P should have referred the baby to a specialist or monitored the patient himself for signs of anemia requiring treatment. Dr P resolved the lawsuit informally.

The record shows Dr P aggressively addressing the patient's bilirubin issues and carefully monitoring her carnitine course. But they also show no targeted inquiry into hemoglobin patterns after discharge or investigation into the risks that alloimmunization may have had on the baby's ability to produce healthy blood.

Granted, the patient's history presented a very rare set of circumstances for Dr P, and no one chose to call him to talk through the anemia issues directly. The documented warnings on suspect hemoglobin patterns and the written invitations for assistance, however, would probably have had a strong influence on a jury.

This case comes from the "Case of the Month" column featured in the member newsletter published by the Cooperative of American Physicians, Inc. The article was originally titled "Indirect Communications and a Rare Situation Need Special Attention."

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