Dozens of Mistakes Caused Death of Young Hospital Patient, Court Rules

Summary

A mother’s painful quest for answers after her son, Anders, died following a kidney transplant surgery at UCSF in 2015. Despite the surgery's success, Anders suddenly stopped breathing post-op, and after years of legal battles, it was revealed that medical errors, including opioid overdose and failure to monitor, led to his death. Expert testimony and court findings confirmed negligence in his care. The case sparked a broader conversation about patient safety, opioid overdose risks, and the need for continuous monitoring in hospitals to prevent similar tragedies. The family’s fight for accountability continues, despite UCSF's denial of fault.

Takeaways

• 😀 A Danville mother, Melissa Pedersen, seeks justice after her son Anders died following a successful kidney transplant at UCSF in 2015.
• 😀 Anders, a healthy 28-year-old, tragically died from a series of medical mistakes shortly after donating a kidney to his sister.
• 😀 Despite initial claims that Anders may have had a genetic heart defect, the family's investigation revealed errors in his post-surgery care.
• 😀 Anders was not monitored with a pulse oximeter, which could have alerted staff to his dangerously low oxygen levels.
• 😀 A nurse practitioner increased Anders' opioid dose by nearly 400% after surgery, which contributed to his overdose.
• 😀 The combination of the excessive opioid dose and lack of monitoring led to Anders vomiting and ultimately stopping breathing.
• 😀 A lack of response from hospital staff to his deteriorating condition, including not administering Narcan, contributed to his death.
• 😀 Expert testimonies in court highlighted more than 30 failures in Anders' care, including inappropriate opioid use and poor monitoring.
• 😀 UCSF was found negligent in Anders' care, but the hospital did not admit wrongdoing, although it changed its policy for monitoring transplant patients.
• 😀 The tragic case has sparked advocacy for improved patient safety, including the implementation of continuous monitoring for all patients on opioids in hospitals.
• 😀 The Pedersen family was awarded $250,000 in damages, as California law limits medical malpractice awards, but their primary goal was to prevent future harm to others.

Q & A

What was the cause of Anders Pedersen's death after donating a kidney to his sister?

Anders Pedersen died due to a series of medical errors following his kidney donation. The primary cause was an overdose of opioids, specifically Dilaudid, which was administered incorrectly after surgery.

How did Anders' family learn about the medical mistakes that led to his death?

It took five years of investigating hospital records and a lengthy court trial to uncover the details. Medical experts and court testimonies revealed that Anders' death was caused by an opioid overdose, exacerbated by a lack of monitoring and incorrect medication dosage.

What was the initial explanation given by doctors regarding Anders' death?

Doctors initially suggested that Anders may have had a genetic heart defect, but this theory was later disproven by medical experts who reviewed his case.

What were the significant errors in Anders' post-surgery care?

Key errors included a drastic increase in his opioid dose, a failure to monitor his oxygen levels with a pulse oximeter, and a five-hour lapse without checking his vital signs after he stopped breathing.

How did the hospital staff fail to recognize the danger of the opioid dose given to Anders?

Hospital staff did not account for the fact that Anders had just lost a kidney, which would make him more vulnerable to the effects of the high opioid dose. They also failed to consider the potency of Dilaudid and the potential risks associated with it.

What did the court conclude regarding UCSF's responsibility for Anders' death?

The court concluded that UCSF was negligent in its care of Anders, finding that the opioid overdose was preventable and foreseeable. The judge ruled that the hospital's failures contributed to his death.

What steps did UCSF take after the incident to improve patient safety?

Following the incident, UCSF revised its policies to monitor transplant patients with continuous pulse oximetry to track their oxygen levels more closely. However, many other hospitals have yet to adopt this practice.

What is the significance of the Pedersen family's legal action?

While the Pedersen family did receive a $250,000 settlement after UCSF was found negligent, their primary goal was not financial compensation but to bring attention to the medical errors and to prevent other families from experiencing similar tragedies.

What is the broader issue highlighted by Anders' case?

Anders' case highlights the dangers of opioid overdoses in hospitals and the lack of adequate monitoring for patients on opioids, which is a significant issue in patient safety. A study estimates that 180,000 patients are harmed by opioids in U.S. hospitals each year.

What measures are being proposed to prevent opioid-related deaths in hospitals?

The Inpatient Opioid Safety Act, a proposed bill, would require continuous monitoring of all patients receiving opioids in hospitals. Experts believe that better monitoring and alarm systems could prevent many opioid-related injuries and deaths.