At 8:30PM that evening, Mrs. C, who was still intubated, began waking up briefly. Her sister and daughter, who were in the room with her, noted that when she woke up, she would hit her right leg, as if it were bothering her.

At 8:45PM, when Ms. M came in to check on the patient, the family asked Ms. M about this behavior. Ms. M told them that she would make a note of it and report it to Dr. S. Ms. M also advised the family to tell the physician about the issue directly when they saw him.



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When Ms. M left the room, however, she was needed urgently in another patient’s room, and she neglected to make a note in the patient’s chart or to try to find the physician.


At about 9PM, the family saw Dr. S in the hallway and told him that Mrs. C had awakened several times hitting her right leg and trying to mouth something about the leg. 


“Our primary concern right now is her stomach,” Dr. S replied. “We’ll look into the complaint about her leg later, once we’ve taken the breathing tube out.”


Mrs. C’s family was still concerned, however, and at 9:15PM, they gave her a piece of paper and a pen so she could communicate her complaint.

She wrote that her right leg was “hot and numb.” The family showed the note to Ms. M, who advised them to show it to Dr. S when he returned. However, the family never saw the physician again that night. At about 10PM, the family retreated to the waiting room, where they remained all night.