Sent Home or Left Waiting
Sent home: A woman in her 60’s arrives at an emergency room at 9:00 p.m. She has severe belly pain and she has been vomiting. Her heart rate is 116 beats per minute. Normal is 60-100.
She is given fluid through a vein and two doses of a strong pain medicine. A plain image of her abdomen is read as constipation. At 2:00 a.m., she is discharged with a prescription for a laxative.
Her pain never improved in those five hours. Nobody examined her belly again, and nobody rechecked her heart rate before she left.
30-hours later she comes back by ambulance. There is a hole in her intestine. She dies in the operating room.
Admitted and watched: A man in his seventies is admitted at midnight with pain, vomiting, and a swollen belly. He has had three prior abdominal operations.
The admitting physician diagnoses a partial blockage of the small intestine. The plan is the standard one. No food, fluid through a vein, a tube through the nose to drain the stomach, and observation.
The short answer
There are two common failures in these cases, not one.
The first is sending a patient home while their severe pain was never explained and never resolved. No diagnosis. No plan to examine them again.
The second happens to patients who were admitted. A doctor decides the problem will settle on its own, and then nobody changes course as the patient gets worse. A plan to watch and wait is a legitimate plan. But it is only as good as the watching. These cases turn on whether anyone acted on what the watching showed.
Whether either was malpractice comes down to two questions. Did the care fall below what a reasonably careful provider would have done? And would earlier or different care have changed the outcome? Both have to be true.
The rest of this article explains how to tell which happened in your case, and what the records usually show.
Overnight his heart rate climbs from 90 to 125 beats per minute. A nurse pages twice. The plan does not change. In the morning he is told to keep waiting.
On the second afternoon his blood pressure drops. That evening a surgeon opens his abdomen and finds two feet of dead intestine. He never leaves the intensive care unit.
Two more versions bring families to us. A man told his pain two days after a colonoscopy is trapped gas. A woman with a prior gastric bypass whose scan reads as normal, while a loop of bowel is twisted behind her rerouted anatomy.
Contact Us for a Free, Confidential Consultation
Article written by Gregory Unatin, Esq. Greg is a managing partner in the law firm of Lupetin & Unatin, a medical malpractice law firm located in Pittsburgh and serving Western Pennsylvania.
Our practice is limited to high-value catastrophic cases because that is where we can do the most for our clients and for patient safety.
Who is most at risk
Certain patients are far more likely to be badly harmed by a condition that is usually harmless. Those risk factors are well known. They are also written in the chart.
That matters legally. A provider looking at a patient with any of these risk factors is on notice. It should mean a lower threshold to order a scan, to admit, to call a surgeon, and to examine the patient again. Sometimes the chart shows the risk factor and the care shows no extra caution at all. That gap is where a case lives.
Older adults. Pain can be blunted, and fever and a high white blood cell count are often absent. A belly can feel soft while a hole is already there. An older patient can look far better than they are.
Anyone with prior abdominal or pelvic surgery. Scar tissue can trap and strangle a loop of intestine. The more prior operations, the higher the risk, and the harder the exam and the imaging are to read.
Altered anatomy from bariatric surgery. After a gastric bypass the intestine has been rerouted. Loops can herniate through spaces the surgery created. Symptoms are often vague and come and go, and a scan read as normal does not rule it out. These patients need a surgeon who operates on this anatomy.
Anyone on steroids or medicine that suppresses the immune system. This includes transplant patients and people on biologic drugs for arthritis or bowel disease. These medicines hide fever and hide the rigid belly of a perforation.
Patients with diabetes. Pain signals can be blunted, and infection can move faster.
Patients with an irregular heart rhythm or known vascular disease. These are the patients who lose the blood supply to the intestine.
Anyone on a blood thinner. They can bleed into the wall of the bowel or into the abdomen.
Anyone who cannot report pain reliably. Dementia, a stroke, a spinal cord injury, sedation, or a breathing tube. This includes nursing home residents, whose complaints reach a doctor secondhand.
Patients on long term opioid medicine, and patients on dialysis or with liver disease. Pain may be masked, and these patients are more likely to be labeled as seeking drugs. Prior radiation to the abdomen carries its own risk.
Pregnant patients and patients with obesity. In both cases the examination and the imaging are harder. The conditions are no less common.
Very young children, who cannot say where it hurts.
If your loved one was in any of these groups, say so in the first conversation you have with a lawyer.
Â
The signs your loved one needed more than they got
Before discharge
- A fast heart rate. Many charts show vital signs at arrival and none before discharge.
- Low blood pressure, including one low reading followed by a normal one.
- Fever, or a temperature below normal. The low temperature is more dangerous and gets less attention.
- Pain far worse than the examination suggests. This is the hallmark of intestine losing its blood supply.
- A rigid, board like belly, or pain that spikes with movement.
- Vomiting that will not stop, or vomit that turns green or foul.
- A belly that is swelling, with no gas or bowel movement passing.
- Pain that needed repeated doses of strong medicine, with discharge soon after the last dose.
- Abnormal blood work. A high white blood cell count. A high lactate level, meaning tissues are starved of oxygen. A rising kidney value.
- Imaging that was the wrong study or read as unremarkable while the pain continued.
After admission
A decision to watch and wait is often correct. The standard of care is about what happens next.
- Serial examinations. The abdominal exam changes over hours, and repeating it is how these conditions declare themselves. A two-day admission with no documented reexamination is a serious problem.
- The trend in the vital signs, not the single reading. A heart rate climbing from 90 to 125 overnight is the story. Any one number can be explained away.
- Nursing notes and pages nobody answered. Nurses usually know first. Whether any physician came to see the patient, and how long it took, is in the record.
- Whether a surgeon was consulted, and when. Delay in getting a surgeon to the bedside is one of the most common failures here.
- Whether the plan was ever revisited. Waiting has limits. When a patient is not improving, continuing the same plan is a decision, and it has to be justified.
- Repeat imaging and repeat blood work. A rising lactate is a serious warning sign. Neither gets ordered if nobody is looking at the lactate.
- Output from the tube in the nose. Rising output means the blockage is not opening.
- Handoffs and overnight coverage. Patients often worsen at night, under a doctor who has never met them. Whether the concern survived the handoff is discoverable.
- Whether a rapid response team was called, and how late.
Whether your family raised a concern and what happened to it. What you said, and who you said it to, matters. Write it down now.
A checklist you can run tonight
Get out the paperwork. Most of this you can check yourself.
If your loved one was sent home
- Is there a diagnosis on the discharge paper, or only a description like abdominal pain?
- Do the papers show a detailed scan, called a CT scan, or only a plain image, or nothing?
- How many times were vital signs taken? Is there a set from just before discharge?
- What time was the last dose of pain medicine, and what time was the discharge?
- Do the instructions say specifically what would mean return immediately?
- Was there an earlier visit or phone call about the same pain?
- Does anything describe your loved one as anxious, exaggerating, or seeking pain medicine?
If your loved one was admitted
- What was the diagnosis on admission, and did it ever change?
- Can you find a note showing a doctor examined the belly each day, or only the first day?
- Do the vital signs get worse across the stay? Look at heart rate over the whole admission.
- Was a surgeon consulted? On what day, and how many hours after admission?
- Was any imaging repeated after the first scan?
- Was blood work repeated as things got worse?
- Did you raise a concern? Do you remember when, and with whom?
- How long was it from the first sign of trouble to the operating room?
Several yes answers do not prove a case. One does not rule one out. But this is what we ask for first, and knowing it makes your first call with us far more useful.
What none of this proves, and the two questions that matter
Most abdominal pain turns out to be minor. Nobody can scan every patient with a sore stomach, and doing so would cause its own harm. Watching and waiting is often the right call, and most intestinal blockages do open up without surgery. A doctor is not negligent for choosing a reasonable plan that did not work. Some of these conditions harm people who got excellent care.
The legal question is narrower than whether this was a tragedy. It has two parts.
Did the care fall below what a reasonably careful provider would have done in that situation? Would earlier or different care have changed the outcome? Both must be true.
So the argument is not that every sore stomach needs a scan. It is not that every blockage needs an operation. It is that this patient, with these findings already written down by this hospital’s own staff, needed something to change. And nothing did.
The only way to know is to read the records.
How people die from this
Families are handed a cause of death that explains nothing. Sepsis. Peritonitis. Multiple organ failure. Cardiac arrest. Nobody sits down and explains what those words describe.
Here is what they describe.
Infection spreads through the whole abdomen. When gut contents leak out, bacteria go everywhere. The body’s reaction to a serious infection is called sepsis. Blood vessels leak and widen, and blood pressure falls. When it falls far enough the heart cannot supply the organs. That is septic shock. The kidneys stop making urine. The lungs fill. The blood loses its ability to clot.
Dead intestine poisons the body. When a section of bowel dies, the barrier holding bacteria inside it is gone. Bacteria and toxins pour into the bloodstream. From there the path is the same, and it is fast.
Bleeding inside the body. In conditions involving a torn blood vessel or a ruptured pregnancy, nothing stops the bleeding and nothing shows outside. Blood pressure falls until the organs fail.
Vomit is inhaled into the lungs. When the intestine is blocked, everything backs up. A patient who is weak, sedated, or lying flat can breathe that material in.
A collapse with nobody there. This happens at home after a discharge. It also happens on a hospital floor at three in the morning.
These deaths almost always follow hours or days of decline. Someone recorded that decline. Nobody acted on it.
The catastrophic injuries in people who survive
Most abdominal pain resolves, and what follows here is the exception rather than the rule.
But when it does not resolve, the harm is often permanent. Families rarely realize these outcomes trace back to a decision made weeks or months earlier.
The path to almost all of them runs through one thing. An operation far bigger than it needed to be. Caught early, many of these conditions are handled through small incisions in about an hour. Caught late, it means opening the abdomen, removing intestine, and washing out infection.
A permanent bag on the abdomen. When intestine is removed in an infected field, a surgeon often cannot safely reconnect the ends. The bowel is brought out through the abdominal wall and waste collects in a bag. Doctors call this an ostomy. Patients are told it is temporary, but in some cases, it is never reversed because the person never becomes well enough for another operation. It means changing a bag several times a day and rebuilding a diet around it.
An abdomen that cannot be closed. When infection and swelling are severe, surgeons sometimes cannot close the abdomen at the end of surgery. The patient returns to the operating room repeatedly over weeks. Survivors are often left with a permanent defect in the abdominal wall, needing its own major repair later.
Weakness and trouble thinking that never resolves. Weeks in intensive care damage nerves and muscle. People come out unable to walk or grip, and many have lasting problems with memory and concentration. Some recover. Some do not, and everyone around them calls it getting older.
A channel leaking gut contents through the skin. After surgery in an infected abdomen, an abnormal connection can form between the intestine and the wound. It leaks. It is exhausting to manage, it wrecks nutrition, and it can take months to close.
Dialysis that does not stop. Septic shock starves the kidneys. Most people recover kidney function. Some never do. That means four hours in a chair, three days a week, indefinitely, with everything else arranged around it.
Permanent dependence on a breathing machine. When a machine is needed for weeks, surgeons place a tube through an opening in the neck. Some patients are weaned off it. Others go to a facility still attached and stay there.
Losing enough intestine that food cannot be absorbed. This is uncommon, and it is among the most life changing outcomes in medicine. When enough bowel dies and is removed, what remains cannot take in enough nutrition. The person is fed through a vein, usually for life, with a permanent line in the chest and a pump running every night.
Loss of the ability to have children. Where a fallopian tube was lost, or infection spread through the pelvis, fertility can be permanently gone.
Several of these require care for the rest of a person’s life. That care costs an enormous amount, and families are usually the ones paying for it.
The conditions that get missed
- A hole in the stomach or intestine, from an ulcer, an infected pocket in the colon, or a burst appendix. Missed because the pain can ease for a few hours. Learn more about delays in diagnosis of bowel perforation.
- A blockage in the intestine, usually from scar tissue left by earlier surgery. Mismanaged when waiting is continued past the point where it is working. Learn more about small bowel obstruction.
- Loss of blood supply to the intestine. Missed because the person is in agony while the belly feels soft. Learn more about superior mesenteric artery (SMA) occlusion.
- A twisted loop of bowel behind rerouted anatomy after bariatric surgery. Missed because symptoms are vague and the scan often reads as normal. Learn more about internal hernia after bypass surgery.
- Appendicitis. Missed most often in older adults, in pregnancy, in very young children, and when the appendix sits in an unusual place. Learn more about delayed diagnosis of appendicitis.
- A blocked and infected bile duct. Missed when antibiotics are given and the blockage is never opened. Learn more about ascending cholangitis.
- A twisted intestine, or a hernia with intestine trapped in it. Learn more about volvulus.
- A burst blood vessel in the abdomen. Regularly mistaken for a kidney stone. Learn more about delayed diagnosis of aortic aneurysm.
- A pregnancy growing outside the womb that ruptures. Missed when no pregnancy test is done. Learn more about delayed diagnosis of ruptured ectopic pregnancy.
- Severe inflammation of the pancreas that progresses to tissue death.
- A hole made during a colonoscopy, called normal gas pain.
- pocket of pus on the fallopian tube and ovary. Mismanaged when the fever falls on antibiotics and the pocket is never drained. Learn about tubo-ovarian abscess.
How we investigate, and how we build the case
We start with records, and we ask for more than most people expect.
From the emergency room or the office:
- The full chart, including the nursing triage sheet with the first vital signs
- The vital sign flow sheet, with every reading and its exact time
- Nursing notes, which often describe far more distress than the doctor’s note
- The physician note, and whether a repeat abdominal exam was documented
- The medication record, which timestamps every dose of pain medicine
- All laboratory results
- The discharge summary and the instructions actually handed over
- The actual imaging studies, not only the written reports
- Any earlier visit, phone call, or portal message
From the hospital stay:
- The admission history and physical
- Every daily progress note, from the attending, the residents, and any consultant
- The complete nursing flow sheets and narrative notes
- The paging and messaging logs
- Every consultation request, with the time placed and the time answered
- Tube output and fluid records
- Repeat imaging and repeat labs, with their timestamps
- Rapid response records, and transfer records to intensive care
- The operative report, the anesthesia record, and pathology on what was removed
- The call schedule and staffing records for those shifts
Also the autopsy report and death certificate, where they exist, and the electronic record audit trail.
Three of these decide cases more often than the rest.
The operative report is the surgeon’s own description of what they found on opening the abdomen. The pathology report describes the tissue removed, including how much was already dead. Together they show how long the condition had been developing. That is how we prove what would have been found a day earlier.
The audit trail is a hidden log inside the record system. It shows who opened the chart, when, what they viewed, and every change made afterward. It cannot be edited the way a note can. We use it to show whether anyone looked at a result before discharge, and to find notes written or altered after the patient collapsed.
A physician reviews it first. Before any lawsuit is filed, we send the records to a doctor in the same field as the one being questioned. Pennsylvania requires a licensed professional to certify that the care fell below the accepted standard before a case moves forward. Our first step is always a real physician reading a real chart.
Expert witnesses. Nearly every case needs emergency medicine and general surgery. The rest depends on the facts. A hospitalist where the failure happened on the floor. A nursing expert where escalation broke down. A bariatric surgeon where the anatomy was rerouted. A radiologist where imaging was misread or the wrong study was ordered. A pathologist where there was a death. Where your loved one survived with permanent harm, we add more. A rehabilitation physician. A nutrition specialist where feeding through a vein is involved. A life care planner and an economist.
Written discovery. After filing, we send the other side written questions they must answer under oath, and formal demands for documents. We ask for the hospital’s own written policies. Its rules on evaluating abdominal pain and on reassessing a patient. Its rules on when a surgeon must be called. Its nursing escalation and chain of command policy. Its imaging protocols, staffing records, and any internal review.
A hospital’s own policy is powerful evidence. An institution writes down what its staff must do. When its staff does not do it, the hospital cannot easily argue our standard is unreasonable. It wrote the standard.
Depositions. These are sworn question and answer sessions before trial, with a court reporter present. We question the emergency physician, the attending, the residents, and the nurses. We question the consultants and the surgeon who eventually operated. We question hospital representatives about policies and staffing. This is often where a case is won. A doctor may not be able to explain why a heart rate of one hundred and twenty five changed nothing. They have to say so on the record.
The two claims Pennsylvania allows when a patient dies. The law recognizes two, and both are usually brought together. One is for the losses suffered by the family, including what a spouse, child, or parent lost when that person was taken from them. The other is brought through the estate, on behalf of the person who died, covering their lost earnings and their suffering before death.
Frequently Asked Questions
There is a strict deadline, and once it passes a court will not hear the claim. The start date is not always the date of the death or the injury. It can depend on when your family reasonably could have learned that something went wrong, which matters if you were told the outcome was unavoidable. The rules are also different when the injured person is a child. Do not assume you are too late, and do not try to work it out alone.
This is the question we hear most, and the answer is direct. Being admitted is not the same as being treated. A plan to observe a patient carries a duty to act on what the observation shows. Picture a night of worsening vital signs, two pages from a nurse, and no change in the plan. That record is often stronger evidence than any discharge decision. Hospitalization does not protect a case. It usually documents it.
No. If we take your case you pay nothing out of pocket, and we are paid only if we recover money for you.
No. This is the most common reason families wait, and it is unnecessary. We obtain the records ourselves, and we know which ones to ask for.
Cases proceed without one all the time. The operative report, the pathology, and the treating notes usually establish what happened and when.
No. A hospital’s own review is not neutral, it is not binding, and you never see how it was conducted. Families are told this routinely in cases that later prove strong.
No. Those are exactly the patients for whom the warning signs matter most. The risk factors were in the chart, and they should have raised the level of caution rather than lowered it. Existing health problems affect what a case is worth. They do not excuse the delay.
Yes. Write down what you asked, who you asked, when, and what you were told. Families are often the ones who noticed the change first, and what you said can be corroborated by the nursing record.
Probably at a deposition, and at trial if the case gets there. Most cases resolve before trial. We prepare you, and you never answer questions without your lawyer beside you.
Usually a couple of years, sometimes longer. Records and expert review come first, then filing, then discovery. We will give you a realistic timeline once we have read the records.
A claim typically names the providers and usually the hospital, but it is handled and paid by insurers. Many families hesitate here because they liked the doctor. Bringing a claim is about what happened to your family, not about punishing someone you were grateful to.
What to do now
Gather what you have. Discharge papers, hospital paperwork, prescription bottles, bills, and anything saved from a patient portal. Then write down what you remember while it is clear. How much pain your loved one was in. What you told the staff, and who you told. What you were told back. Then call us. We will read the records and tell you honestly whether we believe something went wrong.