Memorial Health amended complaint alleges tracheostomy sentinel bleed was not worked up before fatal hemorrhage
The amended complaint alleges that a 20-year-old tracheostomy-dependent patient arrived at the Memorial Health University Medical Center emergency department on February 10, 2024 with bright red blood coming from her tracheostomy site, which the filing describes as a sentinel bleed. An emergency physician and an on-call otolaryngologist attributed the bleeding to tracheal granulation after a bedside tracheoscopy and planned to send her home. A nurse suctioned the tracheostomy tube before departure, the patient immediately suffered what the filing describes as a catastrophic hemorrhage, and she was pronounced dead the next morning.
Overview
This page concerns a public amended complaint alleging that emergency and otolaryngology providers at Memorial Health University Medical Center did not evaluate a tracheostomy sentinel bleed for a tracheo-innominate fistula before a fatal hemorrhage.
Chronology
The complaint alleges as follows:
- The patient arrived by ambulance at approximately 9:09 p.m. on February 10, 2024 with bright red blood coming from her tracheostomy site, after EMS suctioned a blood clot from the tube in transit.
- A visit diagnosis of hemorrhage from the tracheostomy stoma was documented, and the emergency physician consulted the on-call otolaryngologist.
- The otolaryngologist performed a bedside flexible tracheoscopy, diagnosed tracheal granulation with active bleeding, and recommended discharge with pediatric ENT follow-up.
- EMS returned to take the patient home, suggested further suctioning, and a hospital nurse suctioned the tracheostomy tube.
- The patient immediately hemorrhaged about 300 cubic centimeters into a suction canister and an estimated 200 more onto the floor and bed, and her oxygen saturation dropped into the 60s.
- The patient was transferred to the pediatric intensive care unit, went into cardiopulmonary arrest, and was pronounced dead at 9:34 a.m. on February 11, 2024.
Alleged failures
The complaint alleges the following failures:
- The physicians failed to include tracheo-innominate fistula in the differential diagnosis after a sentinel bleed from a tracheostomy site.
- The bleeding was attributed to tracheal granulation without steps to rule out that more emergent diagnosis, and discharge was planned without adequate investigation.
- Suctioning outside a controlled setting such as an operating room precipitated a catastrophic hemorrhage.
- The amended complaint pleads negligence, wrongful death under O.C.G.A. § 51-4-2, and survival claims for conscious pain and suffering, with expert affidavits under Ga. Code Ann. § 9-11-9.1.