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Fatal Pulmonary Embolism Misdiagnosis in Baltimore

Lee v. Sinai Hospital of Baltimore

Slip and FallThis pulmonary embolism misdiagnosis lawsuit was filed in Baltimore City after staff at Sinai Hospital and ManorCare – Ruxton allegedly failed to provide appropriate precautionary measures for a man with pulmonary embolism risk factors. It was filed in Health Claims Arbitration on February 22, 2018, and it is the 94th medical malpractice case filed in Maryland this year.

Summary of Plaintiff’s Allegations

A 59-year-old man slipped and fell on ice in his backyard. He landed on his back and thought that he hit his head, but he felt no pain and was able to walk back home. Two days later, the man fell again. Feeling nauseous, the man had run into the kitchen, hit his hip against the kitchen table, and fell to the floor. His wife called an ambulance and he was transported to Carroll Hospital Center.

The man stayed at the hospital overnight with an electrolyte imbalance and poor oxygenation levels. His hospitalization was complicated by a history of drinking six to eight beers per day for the last 25 years, so he was provided with measures to treat the symptoms of his alcohol withdrawal. The next morning, the man’s discharge diagnosis included nausea, vomiting, hyponatremia, alcohol withdrawal, liver disease, left hip pain without fracture, and electrolyte imbalance.

Later that day, the man presented to BW Primary Care for a follow-up appointment. He was disoriented, dizzy, weak, and unable to bear weight. Because his condition had worsened so dramatically, the man was directed to the emergency room at Sinai Hospital. At the hospital, the man was diagnosed with multiple pelvic and spinal fractures. Since pelvic fractures and physical inactivity are major risk factors for developing venous blood clots, hospital staff should have provided the man with a variety of precautionary measures including anticoagulant medication, ultrasounds of the veins, and a CT angiography. The hospital records contain repeated orders for venous thromboembolism (VTE) and deep vein thrombosis (DVT) risk assessments and precautionary measures, but the orders were never carried out.

The man also had one hypoxic episode at the hospital. He reported dizziness and his blood oxygen level dropped to 83%, but he quickly recovered after he was instructed to breathe through pursed lips. There is no evidence in the hospital records that any action was taken in response to this episode. The man also had problems with fatigue, lightheadedness, and diminished breath sounds during physical therapy sessions, but medical personnel never drew a connection between his issues at physical therapy and his hypoxic episode.

After spending twelve days at Sinai Hospital, the man was transferred to ManorCare – Ruxton. His discharge medications did not include anticoagulants, and there were no specifications for any other VTE/DVT precautions such as sequential stockings or imaging studies. The man continued to exhibit lightheadedness and diminished breath sounds at physical therapy, and the doctors at ManorCare continued to overlook his many risk factors for developing VTE/DVT.

On his eleventh day at ManorCare, the man collapsed in the arms of the nurse who was assisting him into a wheelchair. The man became unresponsive in his wheelchair and the nurses called an ambulance.

At St. Joseph’s Hospital, the man had a CT scan which showed massive bilateral pulmonary embolus. In other words, the blood clots that had been developing in his deep veins broke off, traveled through the bloodstream, and became lodged in the arteries on both sides of his lungs. He had multiple cardiac arrests, showed evidence of anoxic brain injury, and was in a coma. Because his VTE/DVT went untreated for so long, the blood clots in his lungs cut off the oxygen supply to his brain.

The man’s family decided to discontinue his intubation and proceed with a comfort care approach. He was transferred to a hospice center and passed away several days later. His death certificate lists the cause of death as encephalopathy – a broad term for brain disease.

This medical malpractice lawsuit accuses the defendants of failure to diagnose pulmonary embolism, of failing to administer certain tests which would have allowed them to diagnose pulmonary embolism, and of failing to properly treat decedent for the pulmonary embolism which they failed to diagnose.

Additional Comments

  • The classic pulmonary embolism case is a person who is not very functional who has trouble breathing. That trouble breathing is worse on exertion. The classic cases also have pleuritic chest pain. There may also be edema or swelling of the leg that would indicate a blot clot in the leg that could then move to the lung to cause a pulmonary embolism. So this is not a classical pulmonary embolism case.

  • But hypoxia like this man had is an even stronger symptom than shortness of breath. This is measurable lack of oxygen. Any time there is hypoxia pulmonary embolism should be a differential diagnosis regardless of the signs, symptoms, complaints.

  • Even a small risk of pulmonary embolism is a significant risk because not treating a pulmonary embolism can have very tragic consequences.

  • The man’s alcoholism adds a layer of complication to what could’ve been a straightforward case of pulmonary embolism misdiagnosis, a relatively common type of malpractice lawsuit in Maryland. Low to moderate alcohol consumption has actually been shown to reduce the risk of DVT and pulmonary embolism in older patients, so it could be argued that the emergency room and nursing home staff were distracted by the man’s withdrawal symptoms. This may not be a particularly strong argument, especially in Baltimore City, but it could be enough to make a jury hesitate.


  • Baltimore City


  • Sinai Hospital of Baltimore
  • ManorCare Health Services – Ruxton
  • ManorCare – Ruxton, MD, LLC
  • ManorCare Health Services, LLC
  • An internist/hospitalist

Hospitals Where Patient was Treated

  • Carroll Hospital Center
  • Sinai Hospital
  • St. Joseph’s Medical Center


  • Failing to prescribe anticoagulant medications.

  • Failing to appreciate the significance of the man’s multiple fractures and his increased risk for VTE/DVT.

  • Failing to order CTA, oxygenation stats during every shift, sequential stockings, and/or duplex Doppler.

  • Failing to take action after the man was reported to be hypoxic during therapy.

  • Failing to recognize the importance of diminished breath sounds during the man’s entire admission and in all four quadrants on the day of discharge.

Specific Counts Pled

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