Telemedicine: Failure to Properly and Timely Diagnose Bronchopneumonia Alleged in Child's Death

Allegation

The parents of a 3YOF alleged that pediatricians failed to properly and timely diagnose and treat the patient’s bronchopneumonia via telemedicine and in person, resulting in her death.

Case Details

Pediatrician #1 saw the 3YOF patient via telemedicine. Due to technical issues, a video connection could not be established and the evaluation was limited to audio only. The parent reported that the child had been coughing for a month, producing clear mucus, and had a prior fever that resolved with ibuprofen. The child was eating well and active. She was diagnosed with a viral illness at a prior urgent care visit, and no medications were prescribed at that time.

The child’s past medical and surgical history was unremarkable. Immunizations were up to date, and her last clinic visit had been for a 36-month well exam. Based on the mother’s report, pediatrician #1 diagnosed an upper respiratory infection and advised supportive care with close monitoring. A follow-up visit in 24 to 48 hours was recommended if symptoms persisted.

Four days later, pediatrician #2 evaluated the child during an in-person visit in the home, accompanied by her medical assistant. Pediatrician #1’s record was unavailable due to the visit not yet being closed in the system.

The mother explained that the child had been seen at urgent care for ear pain and mentioned the prior telemedicine visit. The mother reported the child had been febrile and crying excessively for nearly two weeks. She noted decreased urine output, ear pain, and disrupted sleep. The child’s temperature was 100.4°F, pulse 162 bpm, and oxygen saturation 98%. Although she was not in visible distress, she was irritable and cried during the exam.

Pediatrician #2 documented left ear impaction and indicated she could not visualize the tympanic membrane. Oral mucosa appeared bluish, and the child had thick nasal discharge. Lung sounds were clear, and no abnormal respiratory effort was observed. The physician diagnosed the child with an upper respiratory infection with impacted earwax and prescribed an antibiotic. A follow-up for ear wax removal was recommended if symptoms did not improve. The prescription was sent to the wrong pharmacy and not picked up by the mother.

The next day, the child was found unresponsive by her parents. EMS transported her to the emergency room, but resuscitation efforts were unsuccessful. She was pronounced dead at the hospital. The coroner later determined the cause of death was acute bronchopneumonia.

In addition, postmortem pathology identified multiple respiratory pathogens, including adenovirus, coronavirus NL63, rhinovirus, parainfluenza 1, and syncytial virus. Bacteriology revealed organisms with gram-positive cocci.

Expert Testimony

Defense experts supported the care by pediatrician #1 noting his limited exam was due to connectivity issues. However, they found pediatrician #2 breached the standard of care due to inadequate documentation, poor clinical decision making, and failure to clearly record her exam findings and treatment plan. Defense experts also noted her communication style appeared dismissive and uncaring in response to the parent’s concerns.

Resolution

This case was settled.

Risk Reduction Strategies

If your practice includes telemedicine, consider the following:

• Flag high risk patients for in-person evaluation during scheduling.
• Ensure the patient has the technology and connectivity necessary to be adequately examined, the capability to utilize the technology needed, and a condition that does not require an in-person visit. Screen connectivity ability prior to telemedicine visits using a standardized checklist.
• Document any technical issues that interfered with, delayed, or complicated the telemedicine encounter. For example, poor internet connectivity or signal quality, camera or device malfunction, or patient inability to manage the technical aspects of the exam.
• Implement a mandatory escalation policy for poor telemedicine connectivity.
• Document what occurred during the patient exam and explain your thought process, rationale, decision making, and findings. Document follow-up plans and ensure closed loop communication takes place with patients.
• Finalize your medical record notes in a timely manner and ensure the records contain accurate information, such as complete medication lists and correct patient pharmacy.
• Include emergency warning signs in discharge instructions.
• Ensure that open, sincere, and thorough communication takes place with the patient and family. Actively listen, use clear and concise language, show empathy, and foster trust through respectful interactions.

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If you have questions on this topic, please contact us at RiskAdvisor@ProAssurance.com or 844-223-9648.