Risk Management Tools & Resources


CASE STUDY: Failure to Identify Sepsis and Initiate Treatment Leads to Patient Death

Jeanne E. Mapes, JD, CPCU, CPHRM


Case Details

The patient in this case was a 49-year-old female who had a significant medical history, including chronic obstructive pulmonary disease (COPD), coronary artery disease, hypertension, and hyperlipidemia. Her surgical history included placement of two coronary stents and vascular surgery on her left leg.

She presented to the emergency department (ED) on a Thursday afternoon reporting abdominal pain, right flank pain, and shortness of breath. Although the patient had previously been prescribed multiple medications, she stated that she had not taken them for 2 months because of the cost. Her temperature was 101 degrees and her blood pressure (BP) was 187/111 mmHg. Dr. A examined the patient and ordered lab tests, including a comprehensive metabolic panel, complete blood count, urinalysis, urine culture, and blood cultures from two separate sites. He also ordered a computed tomography (CT) scan of the pelvis and abdomen. During the physical exam, Dr. A noted decreased bowel sounds. The patient’s abdomen was soft and tender with no guarding or rebound, but she did have costovertebral angle tenderness in the lower back.

The patient’s lab results were normal with the exception that white blood cells (WBCs) were 16,000/mm3, segmented neutrophils were 98.6 percent, and glucose was 127 mg/dL. Dr. A felt that the elevated WBC count with a left shift indicated a urinary tract infection (UTI). The CT scan of the abdomen and pelvis showed a 5x7 mm stone in the right ureter with moderate right hydronephrosis.

Dr. A believed that the patient’s shortness of breath was due to pre-existing COPD. He ordered and the patient was given ketorolac, ondansetron, and morphine for her pain. Dr. A did not consult the on-call urologist, Dr. U, because the urologist did not like to be contacted unless the patient was going to be admitted to the hospital — and Dr. A did not plan to admit the patient. He felt that pain control was the only possible cause for admission.

The patient was discharged after several hours, and Dr. A’s clinical impression was acute abdominal pain, renal colic, and UTI with fever. The patient was instructed to follow up with the urologist as soon as possible as well as a primary care doctor regarding her other medical issues. She also was given prescriptions for ciprofloxacin and a hydrocodone combination product. Dr. A told the patient where she could have the prescriptions filled for free or very inexpensively. She was instructed to return to the ED if her problems persisted.

The patient returned to the ED early the next morning (Friday), and she was seen by a different emergency physician, Dr. B. She told Dr. B that she had been diagnosed with gallstones the previous day. After reviewing the records, Dr. B came to the conclusion that the patient was confusing gallstones with kidney stones, and he made the assumption that Dr. A had talked to the urologist during the patient’s previous visit.

In actuality, the patient had not yet made an appointment with the urologist or filled her prescriptions. She was still suffering from right flank pain and was rocking on the edge of the bed due to pain. She also stated that she had not urinated very much. The patient’s vital signs were as follows: BP = 151/86 mmHg, pulse = 93 beats/minute, respirations = 24 breaths/minute, and oxygen saturation = 97 percent. She had a temperature of 96.8 degrees.

Dr. B was aware that blood cultures from the previous day were available, and that the cultures showed gram negative rods. However, the sensitivity report was not back to the ED yet. He ordered and the patient was given ondansetron, morphine, ketorolac, and oral ciprofloxacin. The patient didn’t want to take the ciprofloxacin, but Dr. B had a serious discussion with her about the need for the medications and the urgent need to see the urologist. She ultimately was convinced to take the medication.

Dr. B did not order any lab tests or procedures, but he strongly encouraged the patient to contact the urologist that morning for an appointment. She was told to return to the ED if her condition worsened, and she agreed to do so. No documentation exists regarding any conclusions drawn as to the patient’s lack of urination. The patient did fill the initial ciprofloxacin prescription later that day.

The patient returned to the ED for a third time the next day (Saturday), and she was seen by a third emergency physician, Dr. C. The patient was confused and had a fever. She still had not contacted the urologist. Dr. C’s impression was dehydration, neutropenia, urosepsis, and ureterolithiasis.

Dr. C admitted the patient to the hospital, and she had a stent placed in the right ureter by the urologist and was admitted to the intensive care unit. The patient had a difficult course; she developed pneumonia and suffered a massive stroke approximately a week after the third ED visit. Further complications developed, and the patient died several days after having the stroke.

SIRS and Sepsis

SIRS consists of four criteria, and patients must have two or more. The criteria are as follows:

  • Temperature: >100.4° or <96.8°
  • Respiratory rate: >20 breaths/minute
  • Heart rate: >90 beats/minute
  • WBCs: >12,000/mm3 or <4,000/mm3

Sepsis is defined as SIRS plus suspected or confirmed infection.1

The patient’s family filed a lawsuit alleging negligence on behalf of Drs. A and B. The basis of the lawsuit was that the patient met both the criteria for systemic inflammatory response syndrome (SIRS) and sepsis. As such, intravenous antibiotics should have been started, the urologist should have been contacted, and the patient should have been admitted to the hospital. When the patient returned to the ED the second time, she was discharged again despite the physician’s knowledge of the gram negative rods and failure to urinate. The plaintiff’s attorney argued that the delay in care ultimately led to the pneumonia, stroke, and death. After multiple defense experts provided negative reviews of the care provided, the case was settled.


Multiple factors are at play in this interesting and unfortunate case. Clinical judgment and lack of communication are among the top risk factors in diagnostic failures, and both played a part in this patient’s care. In addition, two key issues associated with clinical judgment errors in diagnosis-related malpractice claims are failure or delay in obtaining a consult or referral and patient assessment issues, both of which occurred in this case.

The lack of communication between both ED doctors (Drs. A and B) and the urologist (Dr. U), was a major factor in the outcome of this case. Poor communication is a well-known risk factor for patient injuries. Dr. A’s failure to contact Dr. U, which was due to his desire not to be bothered with patients who weren’t ill enough to be admitted, arguably started the ball rolling on the failures in this patient’s care.

A doctor has a duty to recognize the limits of his/her knowledge and know when to refer the patient to a specialist. Dr. A recognized that he could not provide further care for the patient, but he failed to recognize the urgency of the situation. Dr. A should have contacted Dr. U to have the patient admitted or to get a definitive time for an appointment instead of relying on the patient to do so. Had Dr. U been contacted, he potentially would have had a different opinion regarding hospitalizing the patient, and the subsequent developments might have been averted.

It is possible that Dr. A’s failure to consult Dr. U was out of reluctance to deal with a difficult fellow physician. However, specialists are available so that they can be contacted when the emergency physician feels that the patient’s needs are beyond his/her expertise. Healthcare systems should have written policies in place as to what constitutes professionalism and the consequences of digressions. If a physician is so difficult that his/her behavior deters others from initiating contact when necessary, these situations should be evaluated along with any systems issues that are contributing to the problem. A positive workplace environment improves the experience for all workers and enhances patient safety.

Another opportunity to provide appropriate care occurred when the patient visited the ED the second time. However, during that visit, Dr. B relied on Dr. A’s previous diagnosis and did not evaluate the importance of the gram negative rods and the patient’s lack of urination. The failure to reconcile those findings, which provided additional evidence that the patient was septic, led to the patient being inappropriately discharged again. When new symptoms and other information suggest a worsening condition, the physician must fully evaluate that information and document his/her conclusion.

The patient’s nonadherence with treatment also was an issue in this case. If the case went to trial, that factor could work against the plaintiff. However, the plaintiff’s attorney could make a reasonable argument that the patient’s socioeconomic circumstances contributed to her nonadherence. For example, her failure to follow her medication regimen might be due to limited finances. Her return to the ED without having contacted the urologist and her misunderstanding of her diagnosis (gallstones vs. kidney stones) might reflect a lack of knowledge and understanding based on her level of education. (The patient had only an eighth-grade education.) For these reasons, physicians must do their best to confirm and document that patients understand their diagnoses and treatment instructions. Methods that support comprehension, such as the teach-back technique, can assist in these efforts.

While it is controversial whether sepsis led to the stroke and the patient’s subsequent death, the patient should have received an earlier diagnosis and treatment for her septic condition. Better communication between providers might have prevented this sequence of events from happening, and the patient’s sepsis could have been treated as it developed. Ultimately, this might have prevented the condition from worsening.

In Summary

Sepsis is a medical emergency that requires prompt identification and action. Failures in clinical judgment, communication, and systems can lead to diagnostic and treatment delays that might have grave consequences for patients, providers, and healthcare systems. Visit the Sepsis Alliance and the Surviving Sepsis Campaign® for more resources and tools.


1 Comstedt, P., Storgaard, M., & Lassen, A. T. (2009). The systemic inflammatory response syndrome (SIRS) in acutely hospitalised medical patients: A cohort study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 17, 67. https://doi.org/10.1186/1757-7241-17-67

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