Malpractice Case: Did Error Cause Neurologic Impairment?

Jacqueline Ross, PhD, RN; David L. Feldman, MD, MBA


April 21, 2022

This case illustrates the importance of taking escalating risks seriously and emphasizes the value of early communication among healthcare providers.

An infant was delivered vaginally at 36 weeks by vacuum assist after one pull, with no pop-offs. The infant's head had an abrasion along the vacuum line on the scalp along with caput succedaneum, swelling of the scalp. The infant's head appeared diffusely swollen.

The baby was admitted to the neonatal intensive care unit (NICU) under the care of a neonatologist. The patient was mottled, pale, and hypotonic with a low hemoglobin of 10.8 g/dL (normal range, 15-20 g/dL). The physician suspected fetal maternal transfusion (had a positive antibody) but also had a differential diagnosis of a subgaleal (between the skin on the scalp and the skull) hemorrhage and suggested a blood transfusion. The parents refused the blood transfusion for religious reasons.

The physician ordered an antibiotic and an ultrasound for the following morning. He planned to check the baby's hemoglobin the next morning.

In the afternoon, the nurses recorded the gradually increasing swelling of scalp. They were unable to palpate sutures due to edema. The baby's blood pressure was normal. During the night, nurses noted abnormal movements along with increasing head circumference and swelling of scalp. Nurses called the neonatologist and reported abnormal movements and increasing head circumference.

Around 5:00 AM, the nurse received a call from the laboratory stating that the patient's hemoglobin was 8.9 g/dL, which is far lower than normal. She called the neonatologist, who ordered STAT laboratory tests and an electroencephalogram. At 10:40 AM, the baby was transferred to a larger hospital because of the need for a higher-level NICU.

The receiving neonatologist assessed that the infant was critically ill with profound hypovolemic shock and metabolic acidosis. An ultrasound indicated no intracranial hemorrhage, but an MRI showed profound hypoxic ischemic encephalopathy. The infant's hemoglobin continued to drop. After consult with risk management at the new facility, a blood transfusion was given even though the parents refused the blood transfusion.

The child has microcephaly, profound intellectual disability, cortical visual impairment, seizures, and profound spastic quadriplegia. The parents filed a claim against the neonatologist.

Experts opined that the physician inadequately managed the subgaleal bleeding and caput succedaneum. Fluid replacement was insufficient for the worsening problem. Nurses should have notified the neonatologist earlier of the expanding head measurements, and the neonatologist should have examined the infant when abnormal movements were reported. The neonatologist should have ordered an urgent neurologic consult, they said. This case settled with the hospital and neonatologist.

Tips for Malpractice Risk Reduction: Dr Feldman's 3 P's

  1. Prevent adverse events with effective communication between healthcare providers. The nurses in this case delayed calling the neonatologist about the expanding head circumference. The neonatologist should have considered a neurology consult sooner.

  2. Preclude malpractice claims by providing the patient's family with the most current information about the patient's condition. Be open and honest about the patient's condition. Encourage the patient's family to ask questions during the conversations. Regrettably, in this case, and in cases involving similarly devastating injuries, the best communication may not preclude a malpractice claim. In this case, the physician did not appreciate the potential seriousness of a subgaleal bleed and did not communicate for the patient. The parents' religious beliefs and opposition to blood transfusion resulted in treating the parents over the patient.

  3. Prevail in lawsuits with documentation about your clinical findings, including the response to abnormalities. This claim had documentation of clinical findings, but the documentation lacked follow-up.

This case comes from "A Study of Malpractice Claims Involving Children," published by The Doctors Company.


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