‘Medical Error’ Led to Death of 6-Year-Old Who Developed Pneumonia After Measles Diagnosis

A child who died in a Texas hospital after developing pneumonia following a measles infection died as a result of “medical error” — including failure to administer the correct antibiotic in time, according to a medical expert who reviewed the child’s medical records.

Children’s Health Defense (CHD) obtained the medical records from the family of the 6-year-old girl. The parents said they wanted people to know what happened to their daughter so it wouldn’t happen to other children.

The parents obtained the records from Covenant Children’s Hospital in Lubbock where their child died on Feb. 26.

The parents told Dr. Ben Edwards, who successfully treated their other children for measles, that they didn’t want to use the information uncovered in the medical records to inflame the situation. However, they did want to get the word out about the mistake if it could prevent it from happening to other children.

Dr. Pierre Kory, who has extensive experience in pulmonary and critical care medicine, analyzed the records. He said today in an interview on CHD.TV, “I’ve done medical case reviews from malpractice lawyers for a good part of my career, and this case was tragic.”

According to Kory’s analysis of the records, the girl died from a secondary bacterial pneumonia that had “little to do with measles.”

He added, “When I say it has little to do with measles, secondary bacterial pneumonias can happen after any viral infection.”

Kory said the girl “died of a medical error — and that error was a completely inappropriate antibiotic” for treating the kind of pneumonia she had.

The records showed that the girl was initially admitted to the emergency room (ER) for “secondary bacterial pneumonia,” Kory told The Defender. At that time, her measles rash was already fading.

She was not administered the correct antibiotic for treating her secondary bacterial pneumonia until roughly two and a half days later. By that time, she had declined so severely that doctors had already placed her on a mechanical ventilator, Kory said.

Also, it appears there was a delay of more than nine hours from the time when the correct antibiotic was finally ordered and the time it was given, Kory said. “Less than 24 hours later, she died — and she died rather catastrophically … suddenly her blood pressure crashed and she arrested.”

Medical error is the third leading cause of death in the U.S., according to a 2016 analysis by Johns Hopkins University researchers including Dr. Marty Makary, Trump’s nominee to lead the U.S. Food and Drug Administration.

Hospital initially prescribed inappropriate antibiotic

Kory broke down in more precise medical terms what appears to have happened.

When the girl was admitted to the ER, the staff made a general diagnosis that she had a secondary bacterial pneumonia. “She was clearly being admitted from the community so it was implied that it was a community-acquired pneumonia,” Kory said, referring to how the girl didn’t get the pneumonia from being in a hospital or healthcare facility.

They were “absolutely correct” about that, Kory said.

But what they initially gave her for that diagnosis was incorrect, he said.

Generally, doctors put patients on two antibiotics “to cover all the possibilities” of what specific kind of bacterial pneumonia the patient may have.

Kory said:

“It’s in every guideline — infectious disease, pulmonary — every guideline in the country tells you that for a hospitalized child or adult who gets admitted to the hospital, you put them on two antibiotics.

“One is from a category called beta-lactams, which is like penicillin, cephalosporins. And they [the hospital] got that part correct. They put her on something called ceftriaxone, which was excellent.

“But you always need to pair it with an antibiotic from a different category, which is called a macrolide or a quinolone.”

They didn’t do that part, Kory said. “They didn’t put her on the most common, which is azithromycin.”

Instead, they put her on vancomycin, an antibiotic used for very drug-resistant organisms like MRSA.

According to the Mayo Clinic, MRSA — short for methicillin-resistant Staphylococcus aureus — is an infection caused by a staph bacteria that’s “become resistant to many of the antibiotics used to treat ordinary staph infections.” Most MRSA infections occur in hospitals or healthcare settings, like nursing homes or dialysis centers.

Giving vancomycin to the girl was an inappropriate choice, according to Kory.

He said:

“There’s no reason to think that this child would come in with MRSA from the community, from a Mennonite community. She’s not coming from a facility where a lot of antibiotics are used. So it’s a grievous error and it’s an error which led to her death.”

Hospital didn’t change course of treatment for over two days

The records show that the hospital didn’t adjust the girl’s antibiotics until a test came back showing that she had a type of bacterial pneumonia called “mycoplasma pneumonia.”

According to the Cleveland Clinic, mycoplasma is a single form of bacteria that causes an infection that can occur in different parts of the body, such as the respiratory, urinary or genital tracts.

“The tragedy is that mycoplasma is an extremely common — what we call community-acquired — organism,” Kory said. Azithromycin is very effective against mycoplasma, he said.

The hospital staff finally ordered it for her upon seeing her test results. But they should have ordered it much sooner, given that her bacterial pneumonia was community-acquired, Kory said.

Kory said it wasn’t proper doctoring to let her decline for days without adjusting the treatment they were giving her. “You almost have three full days of a seriously declining medical status with no real changes to her treatment plan.”

He added:

“If I’m taking care of someone, and I’m rounding on them every day and I see that today they’re doing a little bit worse than yesterday. And then the next day they’re doing a little bit worse than the day before, I’m going to review exactly what I’m doing and say, ‘What am I missing? What am I missing? What else can I do?’

“And that didn’t happen until a test showed up on a computer. And that’s just not doctoring.”

By this time, the child was in the intensive care unit. “And from my review of the records,” Kory continued, “the antibiotic was ordered at 11:00 p.m., or approximately 11:00 p.m., and as far as I can tell, it was not administered until 9:00 a.m. the next morning.”

“So not only did you have several days delay of decline without the appropriate antibiotic,” he said, “but then when they realized that they were missing the appropriate antibiotic, it took them, as far as I can tell, 10 hours to administer it.”

By the time the girl received the correct antibiotic, she was already on a ventilator.

Father ‘simply wants the truth out’ so the public can talk about measles vs. vaccine risks

Edwards and CHD Chief Scientific Officer Brian Hooker also reviewed the medical records. They concurred with Kory’s analysis.

Edwards said, “As Dr. Kory’s pointed out, unfortunately this was a big mistake, a tragic mistake — and I agree — a fatal mistake.”

However, Edwards said the girl’s father— who gave CHD permission to report on the medical records — didn’t intend “to inflame the situation or cause more division and more just hot rhetoric.”

Edwards told a brief story to illustrate how divisive the media coverage of the West Texas measles outbreak has been.

The day the girl died, Edwards was in the middle of an interview with a reporter. “I remember that reporter grabbing his phone as the alert just came from the news announcing the ‘first measles death.’”

Edwards said there was “almost a giddiness” in the reporter’s response to the news.

“It was disgusting, actually,” he said. “I want people to know Peter [the father] doesn’t want this information to be used on the other side in the same almost giddiness kind of way of, ‘Aha, we got you.’”

The girl’s father “simply wants the truth to be told so that other kids who potentially could go down the same path as his daughter won’t have to.”

The parents aren’t sharing the information “to give one side more ammunition” in the ongoing public debate around measles.

The father told Edwards, “I love my neighbor — and my neighbor’s my enemy. My neighbor’s the one who hurt me. My neighbor’s the one who offends me.”

Edwards said he wants the public to understand the father’s reason for letting the medical records go public so that “we can maybe come to the table on this.”

Edwards added:

“There’s potential risk — complications and death — from MMR [the measles-mumps-rubella vaccine]. We need to have that conversation at the table, both sides in a truthful, honest manner for the sake of these children.

“That’s what he wants.”

Watch CHD.TV interview with Dr. Pierre Kory: