Medical Malpractice Insights: Back to Basics

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here. Stories of med mal lawsuits can save lives. If you have a story to share click here.

Chuck Pilcher, MD, FACEP

Editor, Medical Malpractice Insights

Back to basics: Take a history. Examine the patient.

And listen to your EMS providers and nurses.


Facts: A 65-year-old male is found by his employer on the floor, unable to speak or get up, lying in a pool of blood from apparent facial injuries. EMS is called, and he is brought to the ED for a reported “slip and fall” with associated facial abrasions. He is awake and denies any preceding symptoms, falls, or loss of consciousness. EMS report includes concern for CVA, with variable documentation of face and extremity weakness. Nursing documentation includes the presence of a facial droop. None of this is otherwise communicated to the ED provider – only noted in reports. Care is limited to cleaning and dressing the patient’s abrasions and he is then discharged. Later that day the patient is found on the front porch of a neighbor’s house. He is confused, his wallet and shoes are missing, and his pants are around his ankles. Facial trauma is noted but EMS has none of the information from earlier in the day. He is transported to a different hospital as possible trauma. There, his initial neuro exam is documented as normal, but a head CT reveals evidence of a possible acute CVA in the right hemisphere. Patient then develops [Editor’s Note: Or perhaps is noted to have] left sided weakness and neglect. He is eventually diagnosed as having a large right ICA thrombus with downstream embolism and MCA infarct. He is treated with aspirin and clopidogrel, but the infarct and symptoms progress. When discharged he requires a feeding tube and continuous care at a SNF. A lawsuit is filed against the first hospital and ED physician.

Plaintiff: Both EMS and the nurse documented the presence of symptoms suggestive of a possible CVA. You either didn’t read that or ignored it. Your exam was superficial and based on your own presumption that this was nothing more than a “slip and fall.” If you had examined my client appropriately, you would have discovered the cause of his “slip and fall.” He could then have been treated for his stroke and not have to be in a nursing home for the rest of his life.

Defense: The defense acknowledged that the discrepancies among the EMS, nursing, and physician documentation were apparent and difficult to defend. They also acknowledged being faced with an involved family and a sympathetic plaintiff with massive damages and the need of high-level lifelong care. Pre-trial settlement negotiations ensued.

Result: The hospital agreed to a seven-figure settlement during mediation. The physician settled for a lesser seven figure amount after refusing to pay the plaintiff’s demand for policy limit.



  • Read the nurses notes. Pay attention to their reports. Discrepancies between nursing notes and physician notes are hard to defend.
  • Seek to have good relationships with your nursing staff. They’re the patient’s advocate and may know something that you don’t. Encourage them to be open with you. EM requires a team!
  • Listen to the history from your EMS providers. They are our eyes and ears in the field.
  • Remember that a “slip and fall” is a symptom, not a diagnosis. One must always ascertain the exact cause of the “slip and fall.” This is especially true with hip fractures in the elderly. The broken hip may be only the consequence of something much more significant (e.g., a stroke or cardiac event).



1. Siedlecki, S., Hixson, E., (August 31, 2015) “Relationships between nurses and physicians matter” OJIN: The Online Journal of Issues in Nursing Vol. 20 No. 3.

2. Speak Your Truth: Proven Strategies for Effective Nurse-Physician Communication. Kathleen Bartholomew RN


Your best teacher is your last mistake.

Ralph Nader


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