Facts

On July 3, 2014, at 9 p.m., Christopher Noteboom, presented with his mother, Karen Noteboom, to Hoag Memorial Hospital Presbyterian's emergency department with complaints of dental pain and head pain. Prior to receiving any further treatment, Christopher and his mother left the emergency department without notifying the emergency staff. Thereafter, he sought treatment with Dr. Garrett at his office. Christopher was then administered an anesthetic to temporarily alleviate his pain.

He returned to the emergency department on July 4, at 1:48 a.m., for severe tooth pain and was triaged by Nurse Mata. His complaints included dental abscess, with 8/10 pain and vital signs of blood pressure 157/118, respiratory rate 18, heart rate 107, temperature 98.2 and Sp02 94 percent on room air. Christopher was also examined by William Park, MD. At approximately 2:21 a.m., Nurse O'Connor administered Dilaudid, 2 mg, IM for pain as ordered by Dr. Park. Christopher's pain level was eight out of 10 at that time.

At approximately 2:30 a.m., Kimberly Akin, RN, noted Christopher was resting quietly with no signs of distress. His breathing was noted as even and unlabored. His mother was at his bedside. His respiratory rate was 18, heart rate 100 and Sp02 93 percent on room air. At approximately 3 a.m., Christopher's blood pressure was 168/91, his respiratory rate 15, heart rate 87 and Sp02 94 percent on non-rebreather mask.

At approximately 3:36 a.m., Nurse O'Connor gave an additional 2 mg of Dilaudid for pain as ordered by emergency physician, Darrin Fryer, MD. Christopher's pain level was 6 out of 10. At approximately 3:38 a.m., Nurse O'Connor noted he was re-medicated as ordered. The patient was educated regarding indications, side effects and monitored for adverse reactions. The patient was also noted to have sleep apnea and placed on a non-rebreather mask.

At approximately 4 a.m., Nurse O'Connor noted the patient's pain level as 3 out of 10. Christopher's blood pressure was 160/96, respiratory rate 15, heart rate 88, temperature 98.4 and Sp02 98 percent on non-rebreather mask. She checked the vitals again at 4:13 a.m. and they were the same. He signed the discharge instructions and was given printed instructions on dental abscess.

According to Karen Noteboom, when they arrived home, Chrisopher got out of the vehicle and walked into his home and directly into his room to lie down on his bed. He asked her to stay with him and to scratch his back while he fell asleep. She scratched his back for approximately 10-15 minutes as he fell asleep and then went to her own bedroom to go to sleep. Plaintiff Spencer Noteboom went in to check on Christopher and touched his leg and it was cold. Spencer Noteboom subsequently called 911 while Karen was administering CPR.

Plaintiff filed suit against the hospital and staff in relation to the death of his son, Christopher.

PLAINTIFF'S CONTENTIONS: Plaintiff argued that the nursing staff fell below the standard of care because they failed to recognize that the decedent was experiencing signs and symptoms of respiratory distress, after the second dose of Dilaudid. Plaintiff also argued that the attending nurse failed to discuss these issues with the ER physician before discharging the patient.

In addition, plaintiff argued that the cause of death was cardiac arrest as a result of respiratory failure brought on by the administration of too much opioid medication. Plaintiff also argued that the level of post-mortem Hydromorphone was consistent with levels found in patients whose deaths were the result of opioid overdose. Plaintiff claimed that Christopher Noteboom died as a result of the defendants' alleged negligence.

DEFENDANT'S CONTENTIONS: The defense argued that administration of approximately 2 mg of Dilaudid on two separate occasions was appropriate and in compliance with the applicable standard of care given the decedent's complaints of pain (8/10) and in relation to the decedent's body mass index (BMI) of 44.1. The medical records indicated that the decedent was never experiencing respiratory distress and was placed on a non-rebreather mask for supplemental oxygen because he had sleep apnea and was unable to fall asleep. The mask was used for comfort and not in response to oxygen desaturation. Nurse O'Connor observed the decedent's vital signs and communicated with the decedent to assess his pain and orientation, and ultimately exercised her clinical judgment that the slight drop in O2 was due to the decedent's physiology versus a side effect of the Dilaudid.

Furthermore, if the decedent was experiencing any respiratory issues due to the Dilaudid, any issues would have been evident within 10-20 minutes following the second administration. In this case, the decedent was discharged approximately 35 minutes following the last administration of Dilaudid, his vitals were normal, and there were no physical signs of distress (Mottled, less responsive, cyanosis).

With respect to causation, defendants argued that the cause of death was dilated cardiomyopathy with coronary artery disease, as stated by the Orange County Coroner's office. The coroner's autopsy finding confirmed the decedent died because he was not getting blood flow to his heart muscle, which set up a fatal arrhythmia. There were two significant occlusions, one to the right artery of 75-90 percent and one to the left artery of 75 percent, which are certainly sufficient to call the death due to coronary artery disease. Dr. Davenport, who performed the autopsy, specially ruled out drug overdose and testified that there were no physical signs of respiratory distress upon examination. Moreover, the levels of Hydromorphone were sub-therapeutic.

As for agency, Hoag argued that decedent was alert and oriented when he read and signed the Conditions of Admission, he had no interaction with Dr. Fryer, and thus had no expectation that Dr. Fryer was an employee of the hospital.

Damages

The jury was asked to return an award between $2.25 million in special and general damages.

Injuries

On July 7, 2014, according to the Orange County Coroner's report, the cause of the patient's death was the result of dilated cardiomyopathy with coronary artery heart disease. According to the toxicology examination, levels of Hydrocodone (Vicodin) were found in the decedent's post mortem blood. The report did not note levels of Hydromorphone (Dilaudid) in the decedent's blood. Although the toxicological examination reported no levels of Hydromorphone in its findings, a review of the actual studies resulted in the presence of Hydromorphone in the system. However, it did not meet the Orange County Crime Lab's limit of detection. In 2014, the detection limit was .010 mg/L.

Result

The jury found in favor of both defendants, Hoag Memorial Hospital Presbyterian and Darrin Fryer, MD, and against plaintiff. The jury found that the defendants did not violate the standard of care in its care and treatment of Christopher Noteboom.

Deliberation

five hours and 40 minutes

Poll

10-2 (in favor of Hoag), 12-0 (in favor of Darrin Fryer)

Length

14 days