Allegation
The defendant physicians failed to timely refer the infant to opthamology for follow-up of retinopathy of prematurity (ROP), resulting in permanent blindness
Case Details
A pre-term newborn female (1 pound, 1 ounce) was born to a methadone and benzodiazepine addicted mother via C-section at 26 weeks, due to breech presentation. The infant was to be put up for adoption. The newborn’s Apgar scores were 3 and 6, and she was floppy and cyanotic. She was sent to the NICU where the neonatologist examined her and informed the birth mother that the infant was in critical condition. Complications associated with prematurity included respiratory distress syndrome (RDS), infections, feeding problems, and ROP. The infant had a cerebral hemorrhage and needed a ventilator and oxygen therapy during the first three weeks of life. While in NICU, ROP protocol regarding oxygen therapy was followed.
A few weeks later, the infant was transferred to a tertiary care NICU at another facility. The plan of care included ROP screening at four weeks. The neonatologist spoke with the adoptive father about possible complications of prematurity including sepsis, need for further antibiotic therapy, and possible need for surgery. The following day, the ophthalmologist began seeing the infant, and noted a grade 2 retinal immaturity of both eyes. Three weeks later, the infant was transferred back to the original hospital, and the adoptive mom and her attorney were called.
The ophthalmologist dilated the infant's eyes the following week. He noted no “plus” disease, and diagnosed stage 1 ROP in the left eye only. The infant was discharged to the adoptive parents with written instructions that included the phone number for the referred ophthalmologist. The documented instructions stated the infant was to be seen within two weeks of discharge.
Three weeks later, the infant presented to the defendant pediatrician for her well-child checkup. The infant's mother informed the doctor that the infant was scheduled to follow-up with the recommended ophthalmologist for ROP. The mother later admitted that when she called the recommended ophthalmologist, he was out on medical leave. She stated she called another pediatric ophthalmologist and the infant was scheduled in six weeks.
The second defendant pediatrician saw the patient a few days later. He spoke again to the mother regarding follow-up for ROP. The mother indicated an appointment had been scheduled. The mother stated it did not occur to her to discuss the specific date because no one had told her there was an urgency.
Approximately one month later, the ophthalmologist examined the infant, and noted a ridge around each retina, indicating bilateral detached retinas. A referral to a laser surgeon and a vitreous specialist was made. Several more experts tried to help the infant without success. She can see light and some colors, but is nearly legally blind.
The plaintiff filed suit alleging the defendant pediatricians failed to discuss with the family the importance of immediate follow-up for the ROP.
Expert Testimony
Defense experts testified the defendant pediatricians met the standard of care and had excellent documentation on instructions to the mother.
Resolution
The case resulted in a defense verdict.
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