Case of the Quarter: Fields v. General Hospital and Joshua Cash, MD
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PRMS

The “Case of the Quarter” column is a sample case study that highlights best practices in actual scenarios encountered through PRMS’ extensive experience in litigation and claims management.  Specific names and references have been altered to protect clients’ interests.  This discussion is for informational and education purposes only and should not be relied upon as legal advice.

Facts:
This is a Northern Virginia case involving the death of a 73 year old male patient admitted into General Hospital behavioral unit for symptoms related to dementia post-op hernia surgery.

The patient, Lyle Fields, was an independent resident at an assisted living facility. Mr. Fields had a history of episodes of anxiety, frustration and aggressive behavior as a resident, but nothing that the staff couldn’t handle. He was examined on October 16, 2014 by his Urologist and a hernia was found. Mr. Fields was referred for surgical consult and was evaluated by Dr. Joshua Cash prior to surgery. Alex, one of Mr. Field’s sons, was concerned about his Dad having separation issues after moving from New York to Virginia and leaving his ex-wife, so he requested Dr. Cash perform a psych evaluation prior to considering surgery.  Mr. Fields had been obsessed with his ex-wife, which affected his anxiety level. A long history of depression and a prior diagnosis of Alzheimer’s Dementia had been reported by his son.

As requested, Dr. Cash performed an evaluation and found Mr. Fields mood to be anxious and depressed. There was no evidence of any hallucinations or delusion. He was diagnosed with Depressive Disorder NOS and Alzheimer’s Dementia and was started on Buspar and Klonopin. After the psych eval Mr. Fields was evaluated by the surgeon who recommended a laparoscopic procedure for the hernia. The son accepted the procedure and Mr. Fields went into surgery on October 31, 2014.

As a result of the procedure, Mr. Fields stayed in the hospital until November 3, 2014. Upon release, Mr. Fields was taken to the assisted living facility where his behavior and overall mood dissipated.  He became increasingly agitated, verbally incoherent, and violent with the staff. His son requested that he be transferred to the General Hospital behavioral unit to undergo further psychiatric evaluation. There, Mr. Fields remained combative with the nursing staff and was noted to be restless, aggressive, anxious and hostile. Dr. Cash was notified and prescribed a medication cocktail of Haldol 10mg, Ativan 2mg and Benadryl 50 mg. Additionally, PRN orders included Restoril 15mg, Haldol 5mg, every 4 hours, Ativan 1mg, every four hours, and Benadryl 25mg, every 4 hours. Mr. Fields was given this cocktail at 10 pm on November 3, and then again at 8:30 am on November 4. Approximately one hour after the second dose, he was no longer combative, but remained restless and irritable.

Dr. Cash assessed Mr. Fields around noon on November 4 and noted that he was showing more confusion, agitation, and psycho motor restlessness following hernia surgery. Dr. Cash’s impression was Axis I: Alzheimer’s Dementia with Depression, delirium. Axis II: No diagnosis. Axis III: Status post hernia repair, GERD’s hypertension, benign prostatic hypertrophy. Dr. Cash made plans to target what appeared to be significant delirium and to stablish his mood to return him to the assisted living facility. Dr. Cash ordered a dose of Haldol 2mg to be given at 4 pm. After the dose was given, the nurse noted him to be restless, anxious, and hostile. Mr. Fields agitated symptoms never subsided after two more cocktails were administered over the next 16 hours.

Mr. Fields was found unresponsive on November 5, 2014. His death certificate notes that the cause of the death was cardiac arrest.

Two days following his death, a private autopsy was requested by the family, which was performed by Dr. Xavier Smith. Dr. Smith found the cause of death to be combined drug toxicity.

The family filed suit against Dr. Cash and General Hospital alleging that Mr. Fields death was caused by combined drug toxicity, notably a lethal amount of Haldol far exceeding any therapeutic range.

Allegations:
The plaintiff alleges that Defendant Dr. Cash was negligent in his failure to adequately assess Lyle Fields during the ER to psych behavioral unit consult and was negligent in prescribing a lethal/ non-therapeutic dose of Haldol to a geriatric patient with dementia related psychosis.

Defenses:
While this case presents questions of liability, it is anticipated that we can win on the defense that Dr. Cash met the standard of care since the Haldol prescribed and administered to Mr. Fields was not outside the therapeutic range for a geriatric psych patient experiencing delirium and hallucinations, along with agitation and aggressive behavior.  It is disputed as to whether the symptoms were connected to the Alzheimer’s symptoms.

Liability Analysis:
Even though Haldol has a black box warning for increased mortality in elderly patients with dementia related psychosis, a case study revealed that the risk of death between placebo controlled patients and drug treated patients was about 2.6% to 4.5%. Causes of death for these groups varied from cardiovascular reasons or infectious disease. Additionally, while the black box warning specifically states that Haldol injections are not recommended for patients with dementia related psychosis, the Haldol prescribed in this case was for Mr. Fields ongoing delirium, not his dementia.

Take Away:
Plaintiff asserts that the lab work performed during the autopsy revealed drug toxicity sufficient to have caused Mr. Fields cardiac arrest. However, these results are controverted. Several experts have concluded that concentration levels of drugs detected in the blood after rigor mortis has set in are not reliable. While Haldol should be carefully administered and duly considered to geriatric patients (especially those with a history of dementia) manifestations of drug overdose include: 1) involuntary movements; 2) hypotension; and 3) sedation. Mr. Fields did not experience any of these manifestations during his hospitalization at General Hospital.

PRMS
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Medical Professional Liability Insurance for Psychiatrists
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