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Claims Case Study: The Wrongful Death of an Endoscopy Patient

November 8th, 2018

Naomi Tsujimura

Each year in the United States, anesthesia/anesthetics are reported as the underlying cause in approximately 34 deaths and contributing factors in another 281 deaths, with excess mortality risk in the elderly and men.

As safe and effective as modern anesthesia may be, major complications sometimes arise that put physicians at serious risk of malpractice lawsuits. In fact, the mortality rate attributable to general anesthesia is said to occur at rates of less than 1:100,000, but minor adverse events occur at more frequent rates, even in healthy patients. According to a recent Medscape survey of 4,000 anesthesiologists, more than half of respondents reported that they had been named in malpractice litigation at some point during their careers. Fortunately, the survey revealed that only two percent of malpractice cases against anesthesiologists resulted in a verdict for the plaintiff. But when malpractice does occur, the effects can be devastating.

The Case

A 59-year-old male patient presented to his gastroenterologist complaining of prolonged nausea and abdominal pain. The patient had a history of diabetes and multiple heart conditions, including hypertension (high blood pressure), a prior myocardial infarction (blockage), coronary artery bypass grafting surgery (CABG), congestive heart failure, and non-ischemic cardiomyopathy (enlarged heart) that resulted in the placement of an AICD (implanted defibrillator) in 2009. As a result of his cardiac status, the patient was classified as disabled.

In order to diagnose his stomach problems, the gastroenterologist recommended an upper endoscopy for March of 2015. Despite the patient’s cardiac conditions, the physician did not order cardiac clearance prior to the procedure. On the day of the procedure, the insured anesthesiologist noted that the patient had not received the prior two-day clearance by any other anesthesia provider. He then cleared the patient himself on the day of the procedure by asking multiple questions that he felt provided enough information to confirm the patient was eligible for the endoscopy.

After the procedure was complete, the patient exhibited a dangerously low heart rate and abnormally low blood pressure. Following intubation and CPR, the patient was stabilized and transported to the ICU, where he was found to be in cardiogenic shock. Unfortunately, the patient remained non-responsive. He was extubated less than one month following the procedure and expired shortly thereafter.

What Went Wrong

During investigation, it came to light that the pre-anesthesia form completed by the insured physician contained inaccurate information, both identifying the patient as female and noting only mild systemic heart disease with no substantial limitation, in spite of his debilitating heart conditions. In addition, the documentation of post-procedural care was difficult to decipher, and providers present during the procedure had conflicting testimony of the sequence of events.

The insured also misled the surgical center by indicating he was board-certified in anesthesiology, when in reality he had failed the boards twice. The anesthesiologist was felt to have deviated from the standard of care, as no cardiac clearance was requested, the consent form signed by the insured and patient was largely left blank, and a proper initial evaluation was never completed. In addition, the insured pre-populated the post-op record, documenting a “satisfactory recovery with no anesthesia complications” despite the patient being brain dead.

As a result, it was determined that the insured over-sedated the patient given his cardiac condition, ignored clear signs of respiratory arrest, and failed to quickly move the patient to a hospital. The majority of the claimed damages in this case were for loss of companionship, comfort, society, guidance, and protection by the deceased.

Risk Management Takeaways

  • Practices should establish guidelines that outline criteria for determining patient selection for ambulatory procedures.
  • For patients with pre-existing conditions that increase their risk for anesthesia complications, physicians should refer them to an appropriate facility where the procedure can be performed safely.
  • The physician should always complete and document a pre-anesthesia evaluation and examination prior to the surgery or procedure.
  • Patient consent should be obtained and documented for anesthesia care.
  • Practices should develop a written protocol for the safe and timely transfer of patients to a prespecified alternate care facility in the event that extended or emergency services are required.
  • Physicians should always refrain from documenting the final disposition of the patient in the medical record until the patient has been discharged or transferred out of the facility.
  • Practices should develop mandatory training protocols for all care providers and staff relative to pre and post-op processes, documentation, and emergency procedures. They should also implement disciplinary actions as needed when there is a deviation from the standards.


For further guidance on this issue, Medical Mutual members are encouraged to reach out to our Claims and Risk Management Departments at 800.662.7917.

Naomi Tsujimura is a Senior Medical Care Analyst based in Medical Mutual’s Raleigh, NC office.


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