In an unprecedented statement, New York University Hospital has announced that it will dramatically change its emergency room procedures after admitting that 12-year-old Rory Staunton, son of Irish immigrants Ciaran and Orlaith Staunton, who died in their care, was a victim of poor treatment.

The story was first reported by The New York Times on Wednesday.

Rory, nephew of IrishCentral founder Niall O’Dowd, was sent home from the ER after being mistakenly diagnosed by doctors there and earlier by his own pediatrician, as suffering from a stomach virus. He died later from Toxic Shock Syndrome.

Rory had received a cut that became infected on his elbow while playing basketball. 

Key lab blood tests that showed it was a bacterial infection and treatable with antibiotics were never looked at in the emergency room and the family were never informed.

The story was picked up in The New York Times by Pulitzer-prize winning writers Jim Dwyer and Maureen Dowd. The NBC Today Show featured a segment yesterday. The NYU statement was issued on the NBC Today show segment.

“The Staunton case has the potential to yield far-reaching improvements in patient care,” Dr. Paul Spirn, a Harvard Professor of Medicine and a radiologist at Boston’s Deaconess Beth Israel, told The New York Times.

Dr Joshua Needleman, a specialist in pediatric pulmonology at Weill Cornell Medical Center in New York, told the paper that the implications of the Staunton case showed how critical  it was for doctors to keep open minds.

“The big questions are about how to integrate new information that doesn’t fit with the perception you have formed,” he wrote in an e-mail. “How to listen to the patient when they are telling you something that doesn’t fit with your internal narrative of the case. These are the hardest things to do in medicine and yet the most important.” Dr. Needleman said he will use details of the Staunton case to teach those points to medical students and stated that he “was grateful that the boy’s parents had disclosed the painful details.”

In their statement, NYU stated that emergency room physicians and nurses would be “immediately notified of certain lab results suggestive of serious infection, such as elevated band counts.” Rory Staunton’s bands, a type of white blood cell, were nearly five times as high as a normal level but no alarm was sounded.

The statement continued; “Following our review of the events that led to this tragic loss, we have implemented corrective actions and are in the process of designing additional care processes...we have developed a new ED Discharge Checklist to make certain that the treating physician and nurse conduct a final review of all critical lab results and patient vital signs prior to the patient being discharged .”

The statement goes on to say that if the patient has left the hospital when the tests come back, the patient will be called and the information will be shared with the referring physician.

“Keeping our patients safe is our first priority and we want to prevent this situation from happening again.”

Dr. Robert E. Lynch, the director of pediatric critical care at Mercy Children’s Hospital in St. Louis, told the Times that Rory’s lab results were “virtually incompatible with a diagnosis of viral gastroenteritis,” which is what Rory was treated for.