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Not Following Hospital Policy Counts Against Nurse in Lawsuit

You know how important it is to follow each hospital policy to the letter. This includes your chain of command policy when a patient care issue exists and you are not getting the physician or another healthcare provider to heed your concerns.

A hospital policy can be introduced into evidence during a trial to determine whether you upheld your responsibilities under them or failed to do so.

In the 2020 Maryland Court of Special Appeals case of Adventist Healthcare, Inc., et al. v. Susan Mattingly, the court’s decision underscored many interesting legal points, including the importance of following a hospital policy in protecting a patient.

Patient Gets Admitted

A male patient was admitted to the hospital with complaints of abdominal pain. He was diagnosed with diverticulitis and a perforated colon. He had had a sigmoid colectomy and a colostomy before his admission.

During the hospitalization, a decision was made to reverse the colostomy, and he underwent an anastomosis of the colon. The patient was to be carefully observed since one of the possible risks of the surgery was an anastomotic leak.

Initially, the patient progressed “normally” during recovery and was monitored by his physician.

However, four to five days after surgery, the patient complained of pain. He called his mother, upset and crying, told her he was dying and asked her to come to the hospital as soon as possible.

When she arrived at the hospital, her son was “panting” and “breathing very heavy.” The patient poured a pitcher of water over his head and began vomiting bile. The mother immediately contacted the nursing staff.

Nurse M was assigned to the patient during the day shift and was informed by the night nurse that he had been complaining of pain. She assessed the patient, observed his stomach was distended and tender to the touch. Concerned, she contacted the patient’s physician.

The physician ordered a STAT X-ray and ordered the patient NPO except for ice chips.

Patient’s Condition Deteriorates

About 30 minutes after her first call to the physician, Nurse M called again, telling him the X-ray was not done yet and the patient’s mother was asking for him. The physician responded that he was “on the way.”

After the call to the physician, the patient had a high respiratory rate, labored breathing, elevated temperature, high peripheral pulse rate and low blood pressure.

Nurse M called the physician again. He said he was on his way and spoke with the patient’s mother by phone.

After the X-ray (approximately two hours after it was ordered), the patient returned to his room “in bad shape” and “could hardly breathe.”  Shortly thereafter, the patient began foaming at the mouth, his eyes rolled back, and he became unconscious.

Code Blue was called in an attempt to revive the patient.

A hospitalist called the physician, who had not yet arrived at the hospital, and informed him that the patient had coded.

The patient was unable to be revived and died.

The physician arrived at the hospital approximately 4 ½ hours after Nurse M’s initial call.

Mother Arranges for Autopsy

Because of her concern about the circumstances surrounding her son’s death, the mother had a private autopsy done.

The autopsy was not videoed, neither the hospital nor the physician was informed of the procedure, and the individuals who performed it did not know if any potential allegations of professional negligence were to follow the procedure.

Mother Files Lawsuit

The mother filed a wrongful death lawsuit and survival claim (on behalf of the late son’s estate for damages he incurred before his death) against the physician for breaching his standard of care by failing to timely diagnose and treat her son’s medical problems after surgery.

She also named the hospital, alleging that Nurse M, an employee of the facility, was negligent for failing to follow hospital policy and call a “blue code” earlier when the patient’s condition worsened.

The physician/surgeon expert witness testified that the patient died of “terminal septic shock” because of a defect in the surgical anastomosis of the colon, which resulted in leakage of “feculent stool” into the abdominal cavity.

Such an event required immediate surgical intervention, which did not occur.

The jury returned a verdict at trial in favor of the mother and against both defendants. The defendants appealed that decision.

Appeals Court Decision

Expert witness testimony in support of both parties’ legal position is essential in any professional negligence or wrongful death case. Because this blog focuses on nursing, the court’s decision concerning Nurse M’s conduct, based on expert witness testimony, is my main focus.

One of the defendants’ arguments raised on appeal is the expert witness testimony for the mother regarding Nurse M did not present evidence of causation.

In short, the defendants alleged Nurse M breached her standard of care by not following the hospital’s policy on Chain of Command and not calling the Code Blue team. Thus, the testimony must exist that the breach proximately caused the death of the patient.

The court carefully outlined the testimony of the mother’s nurse expert witness and her physician/surgeon expert witness.

Their testimony supported the fact that Nurse M’s failure to follow the Chain of Command Policy and call a code earlier when the patient’s symptoms were shortness of breath, abdominal pain, sweating, and “extremely concerning” vital signs was a proximate cause of the patient’s death.

The appeals court affirmed the ruling of the trial court.

What This Case Means for You

Nurse M was truly concerned about this patient, as evidenced by her many assessments of him and the calls to the physician.

However, she failed to call a code when she could have by simply following the Chain of Command Policy in effect in the facility. This failure breached her standard of care and resulted in liability.

The hospital policy gave Nurse M full authority to act on behalf of the patient. Unfortunately, she did not exercise this power, and the patient died.

When a patient’s condition continues to deteriorate, you must take affirmative action to prevent a foreseeable and unreasonable risk of harm to a patient. This is not only a legal duty, but an ethical duty as well.


Take these courses to learn more about protecting patients and yourself:

National Patient Safety Goals – Nursing
(1 contact hr)
This course covers the 2019 National Patient Safety Goals for nursing staff in the hospital setting.

Everyday Ethics for Nurses
(7.3 contact hrs)
This course provides an overview of bioethics as it applies to healthcare and nursing in the U.S. It shows how ethics functions within nursing and on a hospital-wide, interdisciplinary ethics committee. The course explains the elements of ethical decision-making as they apply both to the care of patients and to ethics committees. The course concludes with a look at the ethical challenges involved in physician-assisted suicide, organ transplantation, and genetic testing.

Protect Yourself: Know Your Nurse Practice Act
(1 contact hr)
Nurses have an obligation to keep abreast of current issues related to the regulation of the practice of nursing not only in their respective states but also across the nation. Nurses have a duty to patients to practice in a safe, competent, and responsible manner. This requires nurse licensees to practice in conformity with their state statutes and regulations. This course outlines information about nurse practice acts and how they affect nursing practice.

By | 2020-10-20T13:19:55-04:00 October 19th, 2020|Categories: Nursing careers and jobs|3 Comments

About the Author:

Nancy J. Brent, MS, JD, RN
Our legal information columnist Nancy J. Brent, MS, JD, RN, received her Juris Doctor from Loyola University Chicago School of Law and concentrates her solo law practice in health law and legal representation, consultation and education for healthcare professionals, school of nursing faculty and healthcare delivery facilities. Brent has conducted many seminars on legal issues in nursing and healthcare delivery across the country and has published extensively in the area of law and nursing practice. She brings more than 30 years of experience to her role of legal information columnist. Her posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. Visit The American Association of Nurse Attorneys website to search its attorney referral database by state.

3 Comments

  1. Avatar
    Joana Livoti, RN,BS,MS October 24, 2020 at 3:38 pm - Reply

    Thank you for this interesting case scenario! It truly is tragic! I totally agree with the final verdict! I also believe that the nurse should/must have called her Nursing Supervisor early on when she kept calling the patient’s physician properly advising the physician of the patient’s status and the physician did not immediately arrive at the hospital! The nurse was negligent in not calling her supervisor who would have immediately assessed the situation and taken immediate action to obtain immediate medical intervention for the patient.

  2. Avatar
    Nurse Undone October 25, 2020 at 11:19 am - Reply

    Very sad , wondering if the hospital had a rapid response team ? They were put in effect so nurses didn’t get bullied calling a code they should not have.
    The worst cases before the board of nursing are the ones that do not involve nursing work , illegal , or anything to do with nursing. I would like to see a list of worst boards , I am pretty sure AZ would be at the top. I would like to see more articles like this a learning experience for all . We all know this nurse will be calling codes immediately . Wonder also if the chg nurse was aware . Mgt rarely gets taken down.

  3. Avatar
    Stephanie Leah Hall October 30, 2020 at 10:17 pm - Reply

    I have also lost a patient due to a deteriorating patient whose MD negated my concerns. I did call a code as soon as I could, but I wish that I had more authority when my gut kept telling me that something was wrong. The overnight hospitalist (that I had kept up to date of all issues) responded quickly to the code, and the Pulmonologist on-call (who had never seen my patient) – whom the surgeon deferred to – was agreeable to my laboratory requests. My patient passed approximately 5 hours after my intuition kicked in. I kept the family informed at all times. The surgeon finally showed up 15 after the code ended. RN ‘s need to be educated how to navigate these difficult situations. When can you go over your primary MD’s head? How long must an instinct wait? What is the exact chain of command? I only wish that I had done more…

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