A 55-year-old woman with chronic obstructive pulmonary disease (COPD), came to the emergency room due to difficulty breathing. On arrival she had 50% of normal lung function and had suffered a mild heart attack. She was urgently intubated and ventilated. After several days in the ICU, she improved and the breathing tube was removed. Shortly thereafter, a nurse noted bleeding in the patient’s mouth, but did not investigate it, or call a doctor to investigate it. Instead, the patient was sent for an MRI. After the MRI, another nurse noted that blood was running out of both sides of the patient’s mouth and pooling on her bed pillow. Her blood pressure became low, and in an effort to raise her blood pressure, the nurse tilted her bed putting her head lower than her feet, and blood and mouth contents aspirated into her lungs leading her to develop pneumonia. It was not then known, but the bleeding was due to the patient’s partial dentures being lodged in her throat and cutting her throat. Efforts to reverse the injuries were unsuccessful and the patient ultimately died. Had the bleeding incident not occurred she had a 60% chance of leaving the hospital and living for two years. Notwithstanding numerous opportunities to observe the dentures in administering daily oral care, no nurse observed or reported the patient’s partial dentures. Hammond Superior Court, Cause No. 45D01-0411-CT-285.
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