In this case, a female patient from Pennsylvania presented to the emergency room with a broken collar bone. She was taken to the operating room, where doctors used multiple plates and screws to stabilize the fracture. Following a brief period of recovery in the hospital, the patient was discharged home without any issues. A few days after returning home, the patient noted that she had trouble breathing after a prolonged period of standing, at which point she returned to the hospital for evaluation. Imaging taken of her chest revealed the presence of multiple pulmonary emboli, and she was admitted to the ICU for treatment and observation. Following a period in the ICU the patient’s condition improved, however the treating physician failed to note findings from multiple tests in the patient’s records. Furthermore, the patient and her family were not advised of these test findings.
Some time after her discharge from the hospital, the patient returned for a procedure to remove the hardware placed on her collarbone in order to stabilize her initial fracture. The patient and her records were evaluated by the surgeon, who determined that she would be able to undergo the surgery without performing any additional diagnostic testing. The patient was discharged home after undergoing this second procedure. Several days later the patient was discovered dead from new pulmonary emboli.