Daniel E. Holloway
Email me about your case
Georgia case library

Children’s Healthcare of Atlanta at Scottish Rite complaint alleges a family got no neutropenia information before fatal sepsis

The complaint alleges that a hospital team diagnosed a fourteen-year-old with severe neutropenia and mononucleosis. She was discharged without an explanation of the neutropenia or its risks. Four days later her parents called the hospital to report fever, vomiting, and diarrhea. A nurse charted that Melinda Pauly, M.D. told the father to follow up with the pediatrician for symptom management and next steps. The pediatrician, believed to be unaware of the neutropenia diagnosis, recommended an anti-nausea medication. The next afternoon the patient arrived by ambulance, went into septic shock, suffered cardiac arrest, and was pronounced dead.

System
Children’s Healthcare of Atlanta
Facility
Children’s Healthcare of Atlanta at Scottish Rite
Providers involved
Children’s Healthcare of Atlanta, Inc. / Scottish Rite Children’s Medical Center, Inc. / Children’s Physician Group Specialty Providers, LLC / Melinda Pauly, M.D.
Pattern
Alleged failure to clearly explain a severe neutropenia diagnosis and direct urgent evaluation when fever and vomiting developed
Harm
Alleged sepsis, cardiac arrest, and death of a 14-year-old patient

Overview

This page concerns a public complaint alleging that a hospital’s hematology-oncology team did not disclose a severe neutropenia diagnosis before a patient died of sepsis.

Chronology

The complaint alleges as follows:

  1. The patient presented to Children’s Healthcare of Atlanta at Scottish Rite on April 25, 2023, with fever, joint pain, and blood in her urine.
  2. Bloodwork showed a neutrophil count of zero. After a pathologist found her flow cytometry not consistent with leukemia, Melinda Pauly, M.D. diagnosed mononucleosis with profound severe neutropenia.
  3. Dr. Pauly discharged her on April 27, 2023, with instructions to take Tylenol and rest, and scheduled a follow-up for May 16.
  4. A lab panel resulted on April 28, 2023, with abnormalities concerning for significant rheumatologic and immunologic diseases. These were never disclosed to the family.
  5. On May 1, 2023, the parents called the hospital repeatedly to report a fever, neck pain, vomiting, and diarrhea.
  6. A nurse charted that, per Dr. Pauly, the father was told to follow up with the pediatrician. On information and belief, the pediatrician was unaware of the neutropenia diagnosis.
  7. On May 2, 2023, the patient arrived by ambulance ’toxic appearing,’ suffered cardiac arrest, and was pronounced dead at 4:41 p.m. Her final diagnosis was severe sepsis with septic shock.

Alleged failures

The complaint alleges the following failures:

  • Dr. Pauly did not clearly explain the neutropenia diagnosis or its risks to the family at discharge.
  • Dr. Pauly did not clearly instruct the family to seek immediate care if fever, vomiting, or diarrhea developed.
  • On May 1, hospital staff did not recognize the danger of a neutropenic patient’s fever and gastrointestinal symptoms.
  • The hospital and physician group did not adequately train, supervise, or credential the staff who handled her discharge and follow-up.
  • The complaint alleges that the failure to recognize, evaluate, and respond to her fever, vomiting, and diarrhea caused the patient’s death.
  • The complaint pleads negligence against the physician, and respondeat superior plus negligent training and credentialing against the entities. The complaint seeks wrongful-death, estate, and punitive damages, supported by an expert affidavit under O.C.G.A. § 9-11-9.1.

Entities and tags

Children’s Healthcare of Atlanta, Inc.Scottish Rite Children’s Medical Center, Inc.Children’s Physician Group Specialty Providers, LLCMelinda Pauly, M.D.Severe neutropeniaSepsisSeptic shockFulton CountyCommunication or follow-up failurePremature dischargeDelayed or missed diagnosisWrongful deathHematology-oncologyPediatricsEmergency medicine