He discharged the patient despite the severe discomfort she was experiencing
The Ontario Superior Court of Justice has found that a doctor in Brampton was negligent in treating an emergency room patient, eventually resulting in the patient’s death.
In Thompson v. Handler, 2023 ONSC 5042, Elisha Shaw went to the William Osler Hospital in Brampton, complaining of significant abdominal pain. Dr. Jeffrey Handler saw her in the emergency room. Dr. Handler ordered an ultrasound and conducted various tests before discharging Shaw the following day, November 17, 2015, with instructions to follow up with her family physician and bariatric surgeon.
Shaw returned home. Her condition deteriorated rapidly, and she was readmitted to the hospital on the morning of November 18. She was diagnosed with acute abdominal pain. The surgeon who saw her was concerned that she had an internal hernia in her small bowel and was at risk of ischemia. The surgeon performed a laparotomy on her, but her condition deteriorated over the next twelve hours.
On the morning of November 19, a significant portion of her small bowel had developed areas of necrosis and had to be removed. However, her condition worsened despite another surgery, and she passed away on November 25.
Shaw’s husband filed a medical malpractice lawsuit against Dr. Handler, alleging that he was negligent in discharging Shaw from the emergency department on the morning of November 17 and failing to refer her for a surgical consult that morning. The plaintiff argued that if Dr. Handler had kept Shaw in the hospital, the surgery on the evening of November 18 would have been successfully performed earlier.
The Ontario Superior Court of Justice ultimately ruled that Dr. Handler’s care of Shaw fell below the standard required of an emergency room physician and was negligent. The court also determined that Dr. Handler’s negligence caused Shaw’s death, as surgical intervention on November 17 would have resulted in a much better outcome for the patient.
Breach of the standard of care
The court noted from the evidence that Dr. Handler knew Shaw was suffering from abdominal pain radiating into her lower back when she first came to the emergency room. The court explained that the key issue in this case was the level of pain that Shaw was experiencing when she was discharged from the emergency department. The defendant argued that there was evidence that Shaw’s pain improved before discharge, but the court disagreed.
The court acknowledged that Shaw’s pain was managed during her stay in the hospital and was lower, at least during the time that she was asleep. However, the only evidence that her pain had lessened during discharge came from Dr. Handler’s testimony and notes.
The court said, “The notes can be described as cryptic at best. I found it difficult to take anything specific from those notes because they were not in order, difficult to read and had no times noted on them other than the time of discharge and the time of the consult with the radiologist.”
The court analyzed the nursing notes and found Shaw had pain on a scale of ten out of ten, and her pain was consistent until her discharge. The court concluded that at the time of discharge, Shaw was still experiencing significant pain that had not improved in any meaningful way since she was admitted. While she was in the hospital, the various medications she received had managed that pain for short periods. However, they had not relieved the underlying pain or addressed the source of the pain. As a result, the court concluded that “Dr. Handler should have been alive to the possibility of an ongoing and unresolved problem.”
Furthermore, the court found that after Shaw was discharged, Dr. Handler received a CT scan that he knew showed the possibility of a hernia. The court said Dr. Handler should have called Shaw back to the hospital and referred her to one of the surgeons on duty for an emergency consultation.
The court said Dr. Handler was mistaken in his view that Shaw’s symptoms had improved, and he had either missed or ignored that Shaw’s pain radiated into her back. Consequently, the court concluded that he fell below the standard of care in his treatment of Shaw.
Causation
The court explained that in order to establish causation, the “but for” test must generally be met. The critical issue was whether a request to return to the hospital urgently to see a surgeon on November 17 would have changed the outcome for Elisha Shaw.
The court found that Shaw died from a significant necrotic bowel that flowed from hernias in her intestines. She died after developing complications after the removal of the necrotic bowel.
The court noted that when Dr. Handler received the report on the CT scan after Shaw was discharged, it was incumbent upon him to contact Shaw and have her return to the Emergency Department. The court further said it was also incumbent upon Dr. Handler to refer Shaw’s case to an on-call surgeon for an immediate consult. If that happened, the court said it was almost certain that an emergency room surgeon would have reviewed Shaw’s chart, leading to a laparoscopic exploration of Shaw’s abdomen on November 17.
The court was satisfied that a laparoscopic investigation would have led the surgeons to discover and repair the hernias that Shaw was suffering from. Based on what should have occurred, the court believed Shaw would have been left with very little if any, impairment from this incident.
Accordingly, the court concluded that “but for Dr. Handler’s negligence in not following up with Ms. Shaw, Ms. Shaw would not have died. Dr. Handler’s negligence caused Ms. Shaw’s death; therefore, he is liable for the damages that flow from that negligence.”
