Daniel E. Holloway
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Children’s Healthcare of Atlanta complaint alleges missed signs of cerebral venous thrombosis before a teen’s death

The complaint alleges that a 15-year-old patient on chemotherapy for lymphoma had weight loss, abnormal vital signs, and severe headaches at two clinic visits. He also had weakness when walking, tingling, and leg pain. His treatment with steroids and L-asparaginase is known to increase the risk of cerebral venous thrombosis. On February 26 and March 2, 2018, providers attributed his headaches to spinal taps. The second time, a physician called them ’likely spinal’ headaches. They proceeded with more intrathecal chemotherapy and discharged him each time. He was found dead at home on March 4, 2018, and an autopsy found a dural venous thrombosis.

System
Children’s Healthcare of Atlanta
Facility
Egleston Children’s Hospital
Providers involved
Children’s Healthcare of Atlanta, Inc. / Egleston Children’s Hospital at Emory University, Inc. / Children’s Physician Group Specialty Providers, LLC / Emory University / The Emory Clinic, Inc. / Emory Pediatrics, LLC / Egleston Pediatric Group, Inc. / Sharon Castellino, M.D. / Frank G Keller, Jr., M.D. / Kathleen Stone, NP
Pattern
Alleged failure to recognize signs of cerebral venous thrombosis in a chemotherapy patient with persistent headaches
Harm
Alleged wrongful death from an undiagnosed cerebral venous thrombosis

Overview

This page concerns a public complaint alleging that oncology providers missed a teenager’s warning signs of a chemotherapy-linked cerebral venous thrombosis before his death.

Chronology

The complaint alleges as follows:

  1. On February 6, 2018, the 15-year-old patient went to the emergency department with two weeks of neck swelling and fever. Further testing soon led to a diagnosis of T-lymphoblastic lymphoma with central-nervous-system involvement.
  2. He began chemotherapy including intrathecal treatment by lumbar puncture and steroids, and was discharged on February 22, 2018, in good condition.
  3. On February 26, 2018, he returned to the oncology clinic with over ten pounds of weight loss, abnormal vital signs, weakness, tingling, and headaches.
  4. The nurse practitioner concluded he had spinal headaches, and the supervising physician concurred. They proceeded with his sixth intrathecal treatment without investigating other causes.
  5. On March 2, 2018, he returned with more weight loss, a severe positional headache, leg pain, and a nurse-reported gait disturbance.
  6. A physician called the headaches ’likely spinal’ and did not indicate further testing was warranted. Only a blood count was run, and he received a seventh intrathecal treatment before discharge.
  7. He was found dead at home on March 4, 2018, and an autopsy found a dural venous thrombosis with bacteremia.

Alleged failures

The complaint alleges the following failures:

  • Providers did not recognize that steroids and L-asparaginase chemotherapy put him at high risk for cerebral venous thrombosis.
  • They did not consider cerebral venous thrombosis as a possible cause of his headaches, weakness, and leg symptoms.
  • No provider ordered hospital admission, a neurology consult, or urgent imaging to investigate his worsening symptoms.
  • Providers proceeded with intrathecal chemotherapy on both visits despite his progressive neurological symptoms.
  • The complaint pleads medical malpractice, vicarious liability, and wrongful death, and attaches two expert affidavits under O.C.G.A. § 9-11-9.1.

Entities and tags

Children’s Healthcare of Atlanta, Inc.Egleston Children’s Hospital at Emory University, Inc.Sharon Castellino, M.D.Frank G Keller, Jr., M.D.Kathleen Stone, NPT-lymphoblastic lymphomaCerebral venous thrombosisDeKalb CountyDelayed or missed diagnosisWrongful deathPediatric oncologyPediatric neurologyNursing