When immigrants provide bogus contact information, clinicians can’t follow up on dangerous test results.

Mrs. C, 35, had been a physician assistant for two years at a clinic in a large urban hospital. The clinic attracted a significant number of immigrant patients. That posed no problems for Mrs. C—until a patient’s mother left false contact information which led to a malpractice suit.

The patient was a 7-year-old girl who lived with her parents and two siblings. Three days before she was brought to the clinic, she had several episodes of bloody diarrhea and apparent dehydration. Mrs. C suspected Escherichia coli O157:H7. Concerned that the little girl might develop hemolytic uremic syndrome (HUS) as a result of hemagglutination, she took a stool sample and told the mother, Mrs. H, how to keep her daughter hydrated. She also asked for a phone number, so she could call if E.coli O157:H7 was detected in the stool sample.

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Three days later, Mrs. C tried to inform the mother about the positive test results only to find that the phone number in the patient’s record was bogus. Mrs. C consulted her supervising physician, who called the hospital’s clinical manager. He took the problem up the chain of command. Following hospital policy, a telegram was sent to the patient’s last known address, but the family did not receive it.

Unfortunately, the child did develop HUS. She returned to the clinic seven days after her first visit with a blood urea nitrogen of 52 mg/dL and a creatinine of 2.4 mg/dL. She was rehydrated intravenously in an attempt to hemodilute her and underwent dialysis three times a week for several weeks before her renal function returned.

After her daughter’s discharge, Mrs. H consulted a plaintiff’s attorney who specialized in representing the immigrant community. He filed suit against the hospital and Mrs. C for failing to contact the parents so the HUS could be treated. The case started with six months of paper discovery, during which the two sides exchanged documents. Depositions began six months later.

Because Mrs. H spoke English haltingly, she testified through an interpreter. She said that during her initial visit to the clinic, Mrs. C told her she would be notified of the test results. She had given Mrs. C her cell-phone number and insisted that Mrs. C “must have copied down the wrong number.”

The woman also denied receiving the telegram. Although she was evasive about where she lived, she stated “this address would have found me,” implying either a friend or a relative lived there and would have gotten in touch.Asked about the harm the delayed treatment had caused, Mrs. H blamed her daughter’s poor grades, hyperactivity, and social aggressiveness on “the brain damage from the blood clots.”

Presumably, she was referring to hemagglutination produced by E. coli O157:H7, which led to the HUS. Mrs. C was deposed next. Working through her notes, she described how she had told Mrs. H she would let her know if the girl had to come back and how Mrs. H gave her the phone number. But, Mrs. C said, the person who answered the phone claimed not to know the little girl or her family.

Next, Mrs. C described her conversation with the clinical manager, who told her a telegram would be sent. Answering the lawyers’ questions, she conceded that she had not con-tacted the police but observed it was not her place to do so.

Expert witnesses on both sides testified next. Surprisingly, they agreed on two points: A pediatric E. coli O157:H7 infection with bloody diarrhea is associated with HUS, and ultimately, dialysis was indicated in this case. But the plaintiff’s expert contended that HUS would not have developed if the little girl had returned to the clinic immediately after the test results came in. The defense expert insisted an early return would have made no difference.

The plaintiff’s expert also attributed the child’s poor school performance and her hyperactivity to “cerebral ischemia” from HUS. However, he acknowledged that medical evidence to support this opinion was scant and conceded that a cerebral MRI was normal.

Settlement negotiations failed when the plaintiff’s attorney demanded $2 million and the defense’s insurance adjuster offered $50,000. And so the case headed for trial, where the little girl sat and her mother sat quietly at the plaintiff’s table. Relatives and friends filled the benches behind them. Across the aisle, Mrs. C sat alone with the hospital’s attorney.

After the plaintiff’s attorney made his emotional opening statement, Mrs. H took the witness stand. Again speaking through an interpreter, she testified that her daughter’s bloody diarrhea kept getting worse and worse, while she sat waiting patiently for the call that never came and the telegram that never arrived. Finally, in desperation, she took the girl back to the clinic, where the child was diagnosed with HUS and renal failure requiring dialysis. The jury looked on sympathetically.

Mrs. H reiterated her claim that the girl’s illness caused her to have problems at school, but under cross-examination, she admitted that her other children also earned poor grades and got into fights. This pattern, the defense attorney argued, implied that the HUS was not responsible for the little girl’s poor academic performance.

The plaintiff’s expert witness blamed the HUS and renal failure on Mrs. C. He insisted the PA was negligent by failing to contact the police or obtain other emergency phone numbers. When the telegram failed to bring the patient back to the clinic, Mrs. C could have gone to the last known address and knocked on the door, he asserted.

Despite any sympathy they might have felt, the jurors didn’t buy any of these arguments. They found in favor of Mrs. C and the hospital.

Legal background

There are no statutes governing how and when a patient must be notified about lab results. A provider’s actions are judged against “the standard of care,” which is defined, from a legal perspective, by jury verdicts. However, clinicians can and should strive to alert patients to positive test results.

Protecting yourself

Immigrant patients may provide false addresses and phone numbers, especially if they are undocumented. Without valid contact information, notification can be impossible.

In this case, Mrs. C could have had the mother fill out a data sheet instead of writing it from her dictation. The information would then have been in the woman’s handwriting and would have eliminated the possibility that Mrs. C made a mistake. Produced at trial, that data sheet would have been convincing evidence that the providers fulfilled their duty to obtain contact information.

It also would have been helpful if Mrs. H had been given written instructions after the initial visit. She would have been told to bring the little girl back in 24-48 hours if there was no improvement and to call for the lab results if she did not hear from the clinic within an appropriate period of time.

Dr. Starr is a retired physician and lawyer in the Austin, Tex., area. His legal practice included defending clinicians in malpractice litigation.