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Correctional Facility Medical Malpractice And Willful Indifference

By: Raymond P. Mooney, PA-C, DFAAPA
Tel: 517-902-1091
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This is a redacted expert opinion in a complicated correctional medical malpractice and willful indifference case. All names are fictional.

Issue

Attorney requested my review and expert opinions concerning the medical treatment provided by three Physician Assistants (“PA”), PA Whitehead, PA Frederick, and PA Phelps to his client Mr. Harrison.

Qualifications

I am a Board-Certified Physician Assistant licensed in Michigan. My license is and always has been in good standing. I have been certified for approximately thirty- seven years and have been continually certified since I graduated from physician assistant school. My clinical experience includes family medicine, urgent care medicine, emergency medicine, and correctional medicine. More specific information concerning my correctional duties and responsibilities can be found on my attached resume.

Background

Mr. Harrison is a 44-year-old male who was incarcerated at WDOC in March of 2008. The records indicate that he had ankylosing spondylitis and was treated for this condition with Remicade.

After being incarcerated at WCC on March 19, 2008, he was assaulted. This assault was captured on videotape. Several corrections officers' statements are in the records submitted to me. Bates page 01-600114 states that inmate Harrison 'stated that his neck hurt, and I directed him to lie down on the ground and not move until medical arrived.' However, Bates page 01-600121 states Harrison and Hogan (were) told to stop fighting.

Mr. Harrison was placed in wrist restraints and transported to the infirmary for a medical evaluation. Both offenders were seen and released to the IMU by RN Smith.

On March 25, 2008, (Bates page 01-700460), Mr. Harrison was seen by PA Whitehead, who documented that the visit was for a checkup due to a recent assault. He also notes a long history of ankylosing spondylitis. His physical examination demonstrated  decreased range of motion with flexion and extension and tenderness to deep palpation of the paravertebral muscles and the entire spinal column. PA Whitehead prescribed M.S. Contin, Remicade, Robaxin, and Vistaril.

Dr. Chang examined Mr. Harrison on April 7, 2008, and ordered x--rays of the patient's right shoulder and thoracic spine. He renewed Mr. Harrison's M.S. Contin and ordered Neurontin. No radiographic examinations were performed on Mr.
Harrison while he was an inmate at WCC.

On April 13, 2008 (Bates page unreadable), Mr. Harrison was seen by an unknown nurse. Mr. Harrison voiced concern about his spine and stated that he was losing strength in his hands and that he had been unable to void since April 12, 2008. A straight catheterization was performed, and the notes indicate 1,200 ccs of urine were obtained. A physician assistant (name unreadable) was notified, and Mr. Harrison was to see Dr. Chang the following day.

On April 14, 2008, a CHAIN intake (Bates page unreadable) at TRU by a registered nurse noted Mr. Harrison's extensive medical history, including his ankylosing spondylitis, his history of an assault where he was kicked in the back, and his being in a wheelchair and able to walk only short distances. Mr. Harrison also stated that his left leg was numb. He was advised to see a provider.

On April 14, 2008, (Bates page unreadable), a note timed 13:10 states that Mr. Harrison was unable to urinate, unable to change his clothes, and had an increased loss of strength and functioning since his documented and video-recorded assault. It is again documented that he was straight catheterized with a urine output of 1,600 ccs.

On April 14, 2008, a note timed 16:30 hrs. (Bates page 01-700789) indicates that Mr. Harrison was admitted from TRU after complaining of urinary retention. It documents his assault and that he had not voided for two days, as well as his history of ankylosing spondylitis.

PA Frederick notes that he is aware of the assault and that Mr. Harrison had requested straight catheterization twice in the past twenty-four hours because of his inability to void. It is noted that he has bladder dysfunction and a urethral stricture. The specific etiology for this bladder dysfunction is not stated. PA Frederick felt this urethral stricture should not cause any outlet obstruction. PA Frederick's evaluation indicates decreased sensation and balance deficits while questioning its legitimacy. A rectal examination was not performed.

Mr. Harrison's admitting diagnosis by PA Frederick was multiple medical problems, chronic, recent assault with complaints of weakness in his upper and lower extremities, and bladder dysfunction requiring straight catheterization.

On April 14, 2008 (Bates page 01-700787), another 1,300 cc's of urine were obtained by catheterization.

On April 15, 2008 (Bates page 01-700774), a nurse's note indicated that the patient had a positive bilateral Babinski sign (Bates page 01-700774). This nursing sheet also documents that the door is left open during meal times, the inmate is to use the day room for meals, and that Mr. Harrison complained of no feeling in his groin area. At 0730 hours, on March 16, 2008, Mr. Harrison, according to the nursing documentation, attempted to sit on the edge of the bed several times but fell back.

On April 15, 2008, PA Phelps performed a neurological examination and determined that Mr. Harrison's findings are exaggerated and that he appears to be malingering.

On April 16, 2008, PA Phelps ordered a psychiatric consultation for hysterical paralysis (Bates page 01-700771).

On April 16, 2008, at 1600 hours, the psychologist Dr. Irwin's notes indicate that Mr. Harrison complained that he could not walk, and by slowly hanging his legs off the side of the bed, he was able to drag himself back to his bunk.

Mr. Harrison was not eating because he could not reach the dayroom for meals, and the staff refused to bring him meals. Dr. Irwin ordered a wheelchair for the patient to go to the dayroom to obtain his nutritional requirements.

On April 17, 2008 (Bates page 01-700782), Mr. Harrison stated he was not refusing to eat but that the staff refused to bring him food. It is also noted on this date that he had not had a bowel movement in five days.

On April 18, 2008, nurses' notes indicated that Mr. Harrison was taken to the dayroom and could eat but unable to lift his legs.

On April 18, 2008, PA Frederick performed a rectal exam noting a loss of sphincter tone and questioned voluntary inability.

On April 18, 2008, Mr. Harrison was seen by Dr. Andrews, who performed an appropriate neurological exam, and he was sent to Providence Everett Center, where he was found to have flaccid paralysis and a fracture of his seventh cervical vertebrae and spinal cord compression.

Materials Reviewed in Preparation for Expert Opinion

  • Jurisdiction and venue by Mr. Henderson dated February 8, 2012
  • Jurisdiction and Venue by Ms. Heidi M. Powell dated August 3, 2011
  • Medical records of Mr. Harrison Providence Everett Medical Center and Harborview operative note
  • Department of Correction policies
  • Washington State Department of Corrections Incident Reports
  • Washington State Department of Correction Medical Records, March 23, 2008, through April 18, 2008

Information Submitted with Report

  • "Injuries of the cervical spine in patients with Ankylosing Spondylitis: experience at two trauma centers"

  • "Chance Type Cervical Fracture and Neurological Deficits in Ankylosing Spondylitis"

  • "Clinical management of Injured Patients with Ankylosing Spondylitis"

  • "Nursing Documentation" College of Registered Nurses of British Columbia

  • Curriculum vitae

  • Fee schedule

  • Articles published

  • Cases reviewed in the previous four years

The Eighth Amendment to the Constitution requires correctional officials to provide prisoners with adequate and timely medical care. This also includes dental and mental health care. Adequate care in correctional environments must meet the same quality and standard of care that the inmates would be entitled to if they were in the community and freely choose and access health care providers independently.

A medical record is a document that is maintained to record the history of a patient's medical conditions accurately. Its purpose is to facilitate communication between the providers caring for the patient in question. An essential part of this documentation is the nursing notes. "Through documentation, nurses communicate their observations, decisions, actions, and outcomes of these actions for clients." When providing care for a patient, the documentation is intended to provide a clear and concise chronicle of the nurses' actions, including "information reported to a physician or other health care providers and when appropriate, that provider's response."

Documentation of this information increases the likelihood that the client will receive consistent and appropriate care. "Accurate documentation decreases the potential for miscommunication and errors."' ('Nursing Documentation' College of Registered Nurses of British Columbia).

Deviations in Standard of Care for PA Whitehead

  1. Failure to appreciate the clinical significance of spinal trauma/pain in a patient with ankylosing spondylitis who has recently experienced an assault and has tenderness to his back and paravertebral muscles on physical examination.
  2. Failure to immediately immobilize the cervical spine.
  3. Failing to transfer the patient by ambulance to a hospital with the necessary facilities to evaluate and treat the patient as indicated.

Deviations in Standard of Care for PA Frederick:

  1. Failure to review the nursing documentation and appreciate the excessive volume of urine obtained by straight catheterization (1,200cc April 13, 2008), (1,300 cc April 14, 2008) and (1,600 cc April 14, 2008), which would be consistent with a neurogenic bladder due to spinal cord compression; failure to appreciate the notation of bilateral Babinski signs, which would be consistent with trauma to the cervical spine; failure to appreciate the reported loss of sensation in the perineal area, which would be compatible with spinal cord compression; failure to appreciate Mr. Harrison's continued difficulty with moving his lower extremities and his continued statements that he was unable to walk.
  2. Failure to appreciate the clinical significance of potential spinal injury in a patient with ankylosing spondylitis and a history of a recent assault.
  3. Failure to develop an appropriate differential diagnosis in a patient with ankylosing spondylitis and complaints of weakness in his upper and lower extremities, a history of a recent assault, urinary retention, and evidence of neurological deficits.
  4. Failure to realize that Mr. Harrison, more probably than not, had a neurogenic bladder, secondary to a spinal cord injury, due to his history of inability to void and his requests for catheterization.
  5. Failure to immobilize the cervical spine in a patient with complaints of inability to bear weight or use his upper extremities, who has ankylosing spondylitis, urinary retention, and a history of a recent assault.
  6. Failure to transfer the patient to a hospital with the necessary facilities to evaluate and treat  Mr. Harrison for the above abnormalities and complaints.
  7. Demonstrating deliberate indifference to the serious medical needs of Mr. Harrison by ignoring his physical examination findings that indicate decreased sensation and balance deficits, by questioning their legitimacy, and by not performing a required

Deviations From the Standard of Care for PA Phelps:

  1. Failure to review the nursing documentation.
  2. Failure to appreciate the potential clinical significance of numbness in a patient with ankylosing spondylitis.
  3. Failure to appreciate the abnormal findings of the neurological examination of April 15, 2008.
  4. Failure to develop an appropriate differential diagnosis in a patient with ankylosing spondylitis, a history of recent assault, urinary retention, and an abnormal neurological examination, resulting in an impression that Mr. Harrison was exaggerating his symptoms; erroneously ordering a psychiatric consultation for hysterical paralysis without excluding the most urgent and appropriate diagnosis.
  5. Failure to transfer the patient to a hospital with the necessary facilities to evaluate and treat the patient as indicated.
  6. Demonstrating deliberate indifference to the serious medical needs of Mr. Harrison by determining that the findings of his neurological examination are exaggerated and that he appears to be malingering, and subsequently ordering a psychiatric consultation for hysterical paralysis.

Requirements by PA Whitehead to Meet the Standard of Care:

  1. Possess the general medical knowledge that patients with ankylosing spondylitis have a known risk of vertebral fractures, especially of the cervical spine.
  2. Have an appropriate clinical appreciation for the findings of spinal and paravertebral muscle tenderness in a patient who has been recently assaulted and has a history of ankylosing spondylitis.
  3. Immobilize the cervical spine of Mr. Harrison.
  4. Transfer the patient by ambulance to a hospital with the necessary facilities to evaluate and treat the patient as indicated.

Requirements by PA Frederick to Meet the Standard of Care:

  1. Review the nursing documentation.
  2. Possess the general medical knowledge that patients with ankylosing spondylitis have a known risk of vertebral fractures, especially of the cervical spine.
  3. Develop an appropriate differential diagnosis for a patient with ankylosing spondylitis, a history of a recent assault, urinary retention, and evidence of neurological deficits.
  4. Immobilize the cervical spine in a patient with complaints of inability to bear weight, inability to use his upper extremities or urinate who has ankylosing spondylitis, a history of a recent assault, urinary retention, and an abnormal neurological examination.
  5. Transfer the patient to a hospital with the necessary facilities to evaluate and treat the patient as indicated.
  6. Provide Mr. Harrison with the standard of care required by the Eighth Amendment of the Constitution.

Requirement by PA Phelps to Meet the Standard of Care:

  1. Review the nursing documentation.
  2. Possess the general medical knowledge that patients with ankylosing spondylitis have a known risk of vertebral fractures, especially of the cervical spine.
  3. Develop an appropriate differential diagnosis in a patient with ankylosing spondylitis, a history of a recent assault, urinary retention, and evidence of neurological deficits.
  4. Immobilize the cervical spine in a patient with complaints of inability to bear weight or use his upper extremities who have ankylosing spondylitis and a history of a recent assault.
  5. Transfer the patient to a hospital with the necessary facilities to evaluate and treat the patient as indicated.
  6. Exclude the most urgent and appropriate diagnosis before ordering a psychiatric consultation for hysterical paralysis.
  7. Provide Mr. Harrison with the standard of care required by the Eighth Amendment of the Constitution.

I reserve the right to amend these opinions should additional information become available to me. The opinions are based on my experience in correctional medicine.


Raymond P. Mooney, PA-C, DFAAPA is a Physician Assistant with 46 years of experience in Family Practice, Emergency Medicine, Urgent Care, and Correctional Medicine as well as over twenty years of experience in reviewing medico-legal cases. He has extensive experience in deposition as well as trial testimony in state as well as federal court. With a diverse background as a Physician Assistant, Mr. Mooney has been providing the legal industry with his expert opinion for over 20 years. He is available to objectively evaluate cases for alleged medical negligence or a deviation in the standard of care on physician assistant practice.

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