An investigation by the New York State Department of Health into the death of Rory Staunton revealed that his treatment at NYU Langone Emergency Room in New York City did not meet the basic standards of care.
The 12-year-old boy, with Irish-born parents, from Queens, NY died of sepsis on Apr 1, 2012 after a scrape on his arm – from a fall on a basketball court – became infected.
His death and botched treatment at NYU Langone has featured on the front page of The New York Times and on the NBC “Today Show” as well as in many medical journals and "The Dr. Oz Show."
The New York State Department of Health and Human Services Chief Medical Officer have now made their findings public after an investigation concluded on Sept 19 2012.
The investigation stated that “based on document review, interview and an independent physician review, the (NYU Langone) facility failed to provide care in accordance with acceptable standards of practice for both medical staff and nursing services, as well as a systemic failure related to the reporting and follow up of abnormal laboratory results.”
Critically, the report noted that the Emergency Department failed to assure that all pending test results were reviewed prior to the patient’s discharge.
A white cell count taken in the laboratory showed a highly abnormal blood count.
However, it was never seen by the attending physician despite the fact that the tests had been ordered “stat” – or immediately – when he was admitted.
The report concluded that the high blood count “should have raised the physician’s concern for bacterial infection and the need for blood cultures and antibiotic coverage.”
The physician admitted she had not seen the blood results nor had anyone followed up on the results.
The report noted that the final vital signs from Rory were documented at 9:26 when he had a temperature of 102 degrees and his heart rate was elevated to 131 beats a minute.
“The Emergency Department failed to obtain a repeat temperature and heart rate prior to discharge the report noted.
“Nursing and physician staff failed to document a final reassessment of the patient’s condition before discharge,” the report stated.
"The facility failed to have a system in place to notify discharged patients concerning abnormal/critical lab results when the lab results were pending or not reviewed prior to discharge."
Sepsis is a progressive disease where the body’s own systems begin to shut down because of bacterial infection. It is among the greatest killers in America. However, when addressed by immediate antibiotic treatment the condition is very often reversed.
NYU Langone stated in response that they have put into practice a new protocol surrounding emergency room discharges. “Rory’s Regulations” were signed into law in January 2013 by Governor Cuomo, which mandates a final checklist of all tests before a patient is discharged. Cuomo stated at the time that it would help save up to 8,000 lives in New York state.
The family, Ciaran and Orlaith Staunton, from Mayo and Louth respectively, and Rory's sister Kathleen, is now campaigning to have Rory’s Regulations adopted across the United States.