I recently read, as I’m sure many of you did, the New York Times story recounting the illness and death of Rory Staunton. It is a haunting story. . . one that keeps coming back to my mind. The tragic death of a previously healthy twelve-year-old child. A child full of life, cut short.
As a mom, I am devastated for Rory and his family. I cannot imagine the pain. The loss. The hole in their lives that can never be filled. The what ifs and the questions that will likely never fully be answered. This is the kind of story that rocks us as parents. To even imagine the loss of a child. . . . it is unimaginable, unthinkable.
As a pediatrician, I am saddened for the physicians who cared for Rory, and who now are forever changed by his death. His story imprinted on their hearts and brains. This is the kind of story that keeps physicians lying awake at night. Medicine is an ever advancing science. But it is also an art, and an imperfect one. The human body is fantastically complex and sometimes mysterious. We all ask ourselves. . . Did I make the right decision? Did I order the right labs? Did I miss anything? Did I make sure to describe all of the warning signs of when to return? Was my best good enough? Did I make a mistake?
The sad truth is that we are practicing the art and science of medicine in an imperfect system. And, Rory’s death is really a story of systems failure. It is the story of a system that asks physicians to see and do more, instead of doing better. A system that sometimes foments poor communication. A system that failed Rory, his family, and those medical professionals who encountered him in his final days.
Certainly there will be changes to the system at the hospital where Rory was seen. Checks and balances. New protocols. As there should be. But, this is not about one hospital. My hope is that Rory’s death will bring urgency to a movement, already begun, to change the way that medicine is practiced. A movement that is important for both patients and providers. I hope that quality will be valued more than quantity. That counseling and education will be equally valued with procedures. That smart technologies will assist in diagnosis and treatment. That teamwork will be valued. That mistakes will trigger evaluation and improvement, not blame.
Every physician I know desires to heal their patients. Even on our worst days, we all desire to do the right thing. To arrive at the right diagnosis. To first, do no harm. To heal. It is this desire that sometimes drives us to do more, to send more tests, to order a scan. But, there can be harm in this as well. And so, we continue our delicate balancing act of doing just as much as is prudent. Just as much as each patient needs. And still sometimes the illness tricks, defeats. As a pediatrician, I am frequently moved by the honor of caring for children. Every day I work to live up to that honor. But, we are all imperfect, human. This must be acknowledged.
I am haunted by the story of Rory Staunton and other children like him. I hope that time will bring peace to families and others affected. I hope that, in their names, we will create meaningful systemic change and continue to strive for improvement. I hope that we will continue to heal, together.
For more on reducing errors and improving safety in medicine, I highly recommend Dr. Atul Gawande‘s work.
My Two Hats 
systems or people? — the doctors concerned missed incredibly obvious information that was contained in the child’s blood tests. You are giving them a pass. Would you do the same if a pilot crashed a plane? Would you say the systems failed — lets not be afraid to admit human error and lets not pull punches
James- It does appear that errors were made in this case (although I would posit that unless we were there in the ER that day we don’t really know exactly what occurred). This is exactly my point. All doctors, even very smart and well trained doctors, will make mistakes in their career. Systems must be in place to decrease the likelihood of these mistakes occurring in the first place, and to decrease the likelihood that they will lead to the death of a patient. Your comparison with the pilot of a plane is apt, and my response is the same. All pilots will make mistakes in their career. This is why the aviation community has put in place systems- work hours limitations, co-pilots, traffic control towers, alerts, and alarms- which make it less likely that a pilot’s mistake will lead to a bad outcome. The medical community has begun to do the same, but lags behind.
I think we pull punches when we fail to admit that this case could happen in any number of hospitals around the country. When we think this is “incredibly obvious” and could never happen to me. Yes, we must not be afraid to admit human error. We must recognize its inevitability. We must improve the system in order to mitigate the impact of those errors and improve safety for both patients and providers. Thanks so much for reading and for your thoughts.
Thanx for this post Heidi!!! You are awesome!
Great post, Heidi! Though I do think the NY Times article put too much emphasis and not enough research behind the labs. There really wasn’t anything that stood out more than I’ve seen in other cases of gastroenteritis, particularly when we had cases of rotavirus. I’ve seen wbc counts up to 30,000 with significant left shifts and these children were dehydrated but certainly not septic. So, it’s difficult to say this was even a systems issue, since I don’t think getting the labs back earlier would have necessarily changed anything. I guess that’s also because I really teach the residents and students to LOOK at the patient, not the labs, and the blood count hasn’t been shown to be very sensitive nor specific for sepsis. A CRP might have had me worrying more, but those labs would not have equaled an admission in my book.
This is a very sad and unfortunate case, and I can’t even think to imagine what it is like for this family or his doctors. I think we all do the very best we can, and there is the urge to find “blame” somewhere, but sometimes, bad things happen despite our very best efforts.
In terms of systems revisions from this case, hopefully there will not be a push from the ER to admit children on the basis of labs alone, but good followup and instructions for when to return are key.
Also, there was an emphasis on abnormal vital signs on discharge from the ER and the NY Times author seemed to think that size alone dictates your vital signs, but if that were the case, some obese 6 and 7-year-old patients would supposedly have the same heart rate as a young adult! And I really don’t think that is the case. I usually base my vital sign ranges on age, not weight, but it’s an interesting question.
Thank you for a thoughtful and thought-provoking post, Heidi!
Great points, Suzanne. A sobering reminder that we can attempt to improve our systems (and should) but that systems, like people, may never be perfect. You are right that “sometimes, bad things happen despite our very best efforts.” I also agree that I don’t think this case should trigger us to treat or admit based on numbers alone. On the outpatient side, I talk to trainees about a thoughtful discharge- not just sending the patient out the door after their labs are “okay”, but instead spending time talking with the patient/family. When I think about systems reform, I am thinking about things like ensuring that the number of patients seen per shift per doctor remains reasonable and that time taken to counsel/educate/empower families about reasons to return to care is valued. . . these types of changes continue to be idealistic in our current environment. Thanks, as always, for your insightful comments.
Thanks, Heidi! I really appreciate your excellent points too! There is certainly always room for improvement. It would be great to have system improvements where we could focus on time with the patients and their families. I feel fortunate to get more of this time on the inpatient side but even then, it often doesn’t seem like enough! And as you know, it’s difficult because there’s currently no way for the current system to recognize the time spent by physicians with families: the focus is on reimbursement for procedures/surgeries rather than the other “smaller” things we do to keep kids healthy and to keep them from needing procedures/surgeries in the first place.
This is certainly a very, very sad case, but I worry that changes from this may be reactionary rather than well-researched and thought-out. While very unfortunate, this is also a very unusual case, and there are many areas in which changes could have a broader impact. And we need to keep in mind that by doing the more interventional/”conservative” approach, there is a risk of harming patients by doing TOO much as well. It may be difficult for the public to understand, so I worry about cases like this may press physicians to “do more” rather than safely doing less. It’s such a difficult balance!
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