Confidential Attorney Work Project: This is a confidential work project prepared for

Will Win, Attorney at Law. It was prepared in anticipation of or directly related to

litigation.

RE: Mary Mack

DOB: 06/12/1941

Dear Attorney Win:

I have completed my review of Ms. Mack’s medical records regarding her

hospitalizations at Help Hospital and Big City Medical Center, her stay at Senior Care

Center, and Kidney Medical Care from January 2, 2013 – January 8, 2013. I have

included my comments and recommendations at this time for your consideration

regarding this case.

HISTORY: Ms. Mack was a 68 year old dialysis patient with end stage renal disease,

hypertension, diabetes and peripheral vascular disease. Ms. Mack expired on January

8, 2013 at Big City Medical Center. The cause of death was sepsis due to gangrene of

the toe. Ms. Mack’s niece, Rosie Rose, is claiming that Transport was responsible for

an injury to Ms. Mack’s toe leading to the gangrene. Review of all of her medical

records show no indication whatsoever that Transport was responsible for any injury of

Ms. Mack’s toe.

Ms. Mack was transported many times to and from her dialysis treatment by Transport.

Her condition was not unknown to the driver of the van. On 12/20/2012 the driver of the

transport van, Mr. Driver, states in his report that there was a problem with the lift that

raises and lowers the wheelchair. He obtained another wheelchair for Ms. Mack. While

helping her into the wheelchair, Ms. Mack complained of left shoulder pain and left hip

pain. She had her arms around him and states that she heard a “pop” in her left

shoulder and also stated that her left hip felt strained. These were the only complaints

made by Ms. Mack on this day. Mr. Driver completed his report regarding the

malfunctioning lift. There is no mention that Ms. Mack complained of any injury to her

toe. See excerpt (1)

EXCERPT 1

Ms. Mack was taken to Big City Medical Center due to the pain she began experiencing

in her shoulder. Boney Orthopedics were consulted. X-rays revealed a left proximal

humorous fracture. Her left hip x-ray was normal.

With all of these health care providers seeing Ms. Mack, including the nurses, x-ray

technicians, hospital transport, etc., not one person mentioned any injury to Ms. Mack’s

toe. If she had injured it while being transported by Transport, someone would have

noticed it by this point in time. Many providers were visually exposed to Ms. Mack’s

extremities while she was being transported back and forth.

BIG CITY MEDICAL CENTER:

The History and Physical performed by John Henry, PA (Dan Doogle, MD) on

12/20/2012 is only one of many references that show that there was no injury to Ms.

Mack’s toe. Mr. Henry states “Grossly neurological intact. Compartments are soft and

compressible. Toes are up going and down going without complications.” See excerpt

(2) Any healthcare provider performing a physical on Ms. Mack would have noticed and

documented any apparent injury to a toe. Extra attention is paid to any flesh injury of

any extremity of a patient with diabetes and peripheral vascular disease. This PA would

have certainly noticed any abnormality when he was having her flex and extend her

toes.

Excerpt 2 also shows that Ms. Mack denied being dropped and denied a fall while Mr.

Driver was transferring her to the wheelchair.

Excerpt 2

Another reference that shows that there was no injury to the toe is Combine ED

nursing assessment. Under ED Skin-Wounds-Injuries it states: No Skin/Wound

Complaint – yes. This is a bit confusing but it means that “yes, she had no complaints.

See Excerpt (3)

Excerpt 3

Another physical exam performed on 12/20 states that skin is normal, warm and dry.

Looks like the signature is a Dr. Benthere. On the physical exams that I have studied,

they all mention the shoulder; nothing about a toe. See excerpt (4)

DISCHARGE: Ms. Mack was discharged from this hospital stay on 01/5/13. Her

discharge condition was stable. Her discharge note stated nothing about any toe

damage. It was related to her humorous and also a mention of treatment of

hypotension.See Excerpt (5)

Excerpt 4

.

Excerpt 5

SENIOR CARE CENTER:Ms. Mack returned to Senior Care upon her discharge from Big Hospital. A nursing

assessment was performed by S. Jones, RN. As you can see below in her comments,

she has written “skin assessment done….skin warm and intact”. See excerpt (6) This is

yet another reference that there was no injury.

The first mention that I found of the damaged toe was on 1/10/2013. At 5:30 pm either

the niece or patient removed the sock from the foot and was redressing the wound on

the heel (which we have heard nothing of). They found the left great toe was swollen,

blue in color with the outermost skin white. The toe nail had brownish drainage with a

foul smelling odor. Wound care nurse C. Marley examined the toe and stated that it was

not in this condition when she performed the skin exam on 01/06/13. They notified Dr.

Excerpt 6

Bigtoe, a podiatrist to come examine Ms. Mack. At 6:00 pm, the nieces insisted the

patient be transferred to the hospital (Help Hospital) because she was “not acting right”.

She was transferred at 6:40 via EMS. See excerpt (7)

I find it odd that her feet were not examined for 6 days given her medical history;

especially since there was a wound on her heel. Yet, again, this is the first mention of

any problem with the toe. I found no documentation regarding the wound care of her

heel.

Excerpt 7

Senior Care Center has Standing Physician Orders for several different situations.

There is a standing order on treating minor skin abrasions or tears. Yet, I found nothing

in the medical records that indicated any treatment of the heel or any other skin

condition. On the 15th of January, there was an order for Lidocaine 1% 2cc, 5cc

syringe, 21 gauge 1 ½ inch needle, and an 18 gauge needle. I could not find what

anyone intended to do or did with these items.

HELP MEMORIAL HOSPITAL:

On Ms. Mack’s arrival at Help Memorial Hospital ER, she was seen by Dr. Some One.

He stated that Ms. Mack presented to the ER with the complaint of “weakness and left

great toe pain and swelling for several days found by NH nursing and sent here for

exam”. She was evaluated, had some tests and was eventually transferred to Big

Hospital where she sadly expired. I reviewed these records extensively; however I am

not going into detail about these events because they have nothing to do with

Transport.

SUMMARY: After careful review of the medical records provided, I found no

indication that Transport was responsible for any injury to Ms. Mack’s toe nor her

demise. In fact, there is no indication of any problems with her toe during her entire

hospital stay from 01/04-09/2014. The events that occurred at Senior Care Center from

01/09/14 through 01/16/14 are either uneventful or undocumented. I could find no

information regarding a toe injury in their records.

The untimely demise of Ms. Mack was unfortunate and very sad but was unrelated to

her transportation by Transport.

Thank you for allowing me to participate in this case. Please to not hesitate to contact

me if I can be of further assistance. I look forward with eagerness to working with you

again in the near future.

Very Truly Yours,

Debbie Fernando, RN, BS, CLNC, MHA/GER

Certified Legal Nurse Consultant