Avoiding Liability Bulletin – May 2024

According to a 2022 Technical Report in Pediatrics, The American Academy of Pediatrics indicated that approximately 3500 infants die of sleep-related infant deaths (SIDS), ill-defined deaths, and accidental suffocation and strangulation in bed.

The Academy’s Report included its recommendations for a safe sleep environment in order to decrease the risk of all-related infant deaths.

One recommendation is that “infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface designed for infants, ideally for the first 6 months.”

In contrast, bed sharing, where the infant sleeps on the same surface, such as a bed, sofa, or chair, with another person is not as likely to reduce the risk of suffocation, strangulation, and entrapment that might happen when an infant sleeps in an adult bed.

In the following case, whether the nurse and health care team instructed the mother about bed sharing with her newborn was at issue.

Particulars Leading Up to the Case

The infant in this matter was born at 38 weeks of gestation by way of an uncomplicated vaginal birth.  The mother had three (3) other children and was on Medicaid.

The mother and the male infant were discharged two days after his birth.

There was no crib or bassinet for the infant, so the mother and infant slept together in a king size bed.  The mother positioned the infant “lying flat and moving blankets and pillows away from his body.”

The mother noted that the infant “often made grunting noises” when sleeping and did exhibit signs of reflux following feedings.  The mother did not attend a well-baby appointment she was instructed to attend within three days of the hospital discharge, nor did she raise these concerns with any other health care provider.

Six days after being at home, the mother awoke by the infant’s “awkward noise[s] that indicated he was having difficulty breathing. She picked up the infant and realized he was “cold”.  In addition, the infant was “slumped over and his eyes were rolled in the back of his head.”

The mother took the infant to an ED.  The ED physician’s note in the ED record was that the mother told him the infant was having difficulty breathing, was lying on his back when she awoke with him in the bed, and that she did not roll on top of him.

In addition, the ED’s note included that the infant’s arterial blood gases showed “significant acidosis” consistent with asphyxia, his lungs were clear, his “cardiothymic silhouette” was normal, and there did not appear to be trauma or injury to his head or bones.

The infant was transferred via Air-Vac to a children’s hospital and its intensive care unit. He was diagnosed with hypoxic-ischemic encephalopathy and other diagnoses, including anemia, acute kidney failure, intercranial hemorrahges, glysouria, and esophageal reflex metabolic acidosis. 

The etiology of these injuries was not able to be determined.

As a result of these injuries, the infant was diagnosed with cerebral palsy and developmental delays.

The mother, on her own behalf and as the next friend of her son, filed a professional negligence suit against the hospital, and  the physician and the nurse who cared for the infant at the time of his discharge.

 She alleged that the providers failed to instruct her about a safe sleep environment and that due to this failure, her bed sharing with her infant son was the result of his injuries.

Trial Court Proceedings and Decision

The mother had two expert witnesses, one of which was a neonatologist.  Although both were not absolutely certain of the cause of the infant’s injuries, both testified that the injuries were “most likely” and “more likely than not” caused by the mother’s “rolling over” or  by her “passive rollover” of the infant.

Both testified that there were no other factors, such as trauma or a seizure disorder, that would cause such injuries.

The defendant’s expert witness, a pediatric otolaryngologist, testified that the cause of the infant’s injuries was “most likely” a congenital issue with his airway, including laryngomalacia and congenital subglottic stenosis.

The defendants filed a Motion for Summary Judgment, arguing that there was no evidence presented of direct proof of what caused the infant’s injuries.

The trial court granted the Motion, holding that there was a failure to provide any “concrete evidence” as to what caused the infant’s injuries, and that the testimony of the mother’s expert witnesses were “nothing more than speculation.”

The mother appealed the trial court decision.  The basis of her appeal was that the trial court’s ruling that her experts’ opinions were purely speculative was in error.

Appellate Court Decision

The appellate court reversed the trial court’s grant of Summary Judgment.   It held that “absolute certainty” is not the standard in the state for admitting into evidence expert testimony on causation (the reason for the injury).

Rather, the court opined, the basis is a “reliable” basis, even if “absolute certainty” is conceded by the expert(s).

Talking Points

The reversal of the ruling requires that the case be sent back to the trial court for further proceedings. Those proceedings may result in a trial or a settlement. In either situation, the case remains active.

The pivotal issue in the lower court will be whether information about a safe sleep environment was discussed with the mother as part of her discharge planning.

The mother alleged that this instruction was never provided to her while the health care providers. The facility records did indicate that the mother had “knowledge deficits regarding the care of her newborn.” 

The  medical records also indicated that the physician and the nurse “failed to comply with the hospital’s protocol to educate new parents about newborn safety, particularly warning against co-sleeping, and failed to provide the mother with a bassinet and other baby equipment that would normally been given to her as a Medicaid recipient.”  

Discharge planning, which includes patient teaching, is an essential responsibility of nursing practice. Any patient teaching must be clearly documented in the patient’s medical record.

Written instructions or a form developed by the facility which includes all points to be taught to the patient specific to the patient’s medical condition provides a standardized format and allows the patient to take the instructions home.  The form  becomes part of the medical record.

In addition, use of the “teach-back” method helps ensure that the patient understands what is being instructed.

There is no guarantee that a patient will follow completed and documented patient instructions given upon discharge. Even so, a legal challenge to determine whether or not patient instructions occurred would be one less legal issue that would have to be determined in a case similar to this one.

Most important, patient teaching consistent with standards of practice for patient education can result in a patient’s, and in this case, the infant’s, successful transition to home safely and a life without injury or death.

This information is for educational purposes only and is not to be taken as specific legal or other advice by the reader. Nor does it create an attorney-client relationship. If legal or other advice is needed, the reader is encouraged to seek such information from a nurse attorney, attorney or other professional.

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About the Author

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Nancy Brent

NANCY J. BRENT, MS, JD, RN, received her Juris Doctor Degree from Loyola University Chicago School of Law. Ms. Brent has been in practice for over 40 years and concentrates her solo law practice in education and consultation for nurses, nursing organizations, and health care delivery systems. She also defends nurses before the Illinois Department of Financial and Professional Regulation. Ms. Brent has published and lectured extensively in the area of law and nursing practice.