Daniel E. Holloway
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Georgia case library

WellStar Atlanta Medical Center complaint alleges stroke-diagnosis delay before patient’s death

The complaint alleges that a patient arrived at WellStar Atlanta Medical Center South Campus on May 6, 2016, with altered mental status. Providers assumed he was intoxicated and did not perform a stroke assessment or request a neurology consult for hours. A radiologist did not review his stat brain CT until about 4:42 p.m., nearly five hours after he arrived, and misread it as normal. A later MRI showed a massive stroke, but by then it was too late for clot-dissolving treatment. He did not regain any meaningful brain function and died on May 29, 2016.

System
WellStar Health System
Facility
WellStar Atlanta Medical Center South Campus
Providers involved
WellStar Health System, Inc. / WellStar Atlanta Medical Center, Inc. / ApolloMD, Inc. / Jimson Smith, M.D. / F&S Radiology, P.C. (d/b/a and/or a/k/a Radisphere, Candescent Health, Inc., and/or Sheridan Radiology Management Services, Inc.) / Johnny Alexander, M.D.
Pattern
Alleged hours-long delay in stroke screening, CT review, and neurology consultation after an emergency-department presentation
Harm
Alleged massive stroke, loss of eligibility for clot-dissolving treatment, and death

Overview

This page concerns a public complaint alleging that a Georgia hospital and its physicians missed a stroke for hours before the patient’s death.

Chronology

The complaint alleges as follows:

  1. The patient arrived at WellStar Atlanta Medical Center South Campus by ambulance on May 6, 2016, at about 11:52 a.m. with altered mental status.
  2. His providers assumed he was intoxicated and did not perform a stroke screening or request a neurology consult before 5:00 p.m.
  3. An emergency physician ordered a stat brain CT at about 12:05 p.m., but it was not performed until about 2:37 p.m.
  4. The radiologist did not review the images until about 4:42 p.m. and misread them as a normal scan. The images showed findings suggesting an acute clot and suspicious for early infarction.
  5. His condition worsened throughout the day with headaches, vomiting, and diminished movement on his right side. A neurologist was not consulted until about 5:00 p.m.
  6. A brain MRI that evening showed a massive stroke, and he was transferred to another campus around midnight, too late for clot-dissolving treatment.
  7. He did not regain any meaningful brain function after the transfer and died on May 29, 2016.

Alleged failures

The complaint alleges the following failures:

  • The emergency physician did not timely order or ensure stroke screening despite the patient’s altered mental status and nonverbal presentation.
  • The radiologist did not timely read or report the stat CT and did not order additional imaging despite abnormal findings.
  • The hospital and staffing defendants did not have adequate policies for timely stroke imaging, reading, and neurology consultation.
  • The complaint pleads ordinary, professional, and gross negligence, vicarious and direct liability of the entities, estate and wrongful-death claims, and punitive damages.

Entities and tags

WellStar Atlanta Medical Center South CampusWellStar Health System, Inc.ApolloMD, Inc.F&S Radiology, P.C.Ischemic strokeBrain CT scanNeurology consultationFulton County, GeorgiaStrokeDelayed or missed diagnosisImaging misreadDelayed treatmentWrongful deathEmergency medicineNeurologyDiagnostic radiologyStroke care