Many malpractice lawsuits have stories involving tragedy, avoidable or not. This month’s case was particularly painful. [Author’s note – the facts of this case occurred prior to the 2013 FDA issuance of a Boxed Warning and contraindication of the use of codeine in children after tonsillectomy.] 

The patients were 3-year old twin boys, AJ and JJ. Their mother, Mrs J., had brought them for a consultation with Dr L., an otolaryngology specialist after a referral from their pediatrician. The twins were snoring and having sleep issues and the pediatrician suspected sleep apnea. 

After examining the children, Dr L. recommended an adenotonsillectomy and scheduled a date for the surgery. The physician informed the mother that the surgery would not take long and that the children would spend a few hours in the hospital afterwards being monitored, after which they could go home.

The mother had asked the physician whether the boys could stay overnight, however, he explained to her that 3 years of age was the cutoff for inpatient stays for a tonsillectomy and that the boys were now over 3. Worried about taking care of her twins, in addition to her 5-year-old son, the mother asked the physician to verify with the insurance about whether an overnight stay could be covered. 

The insurance company was contacted and Mrs J. was informed that an overnight stay would not be authorized. Mrs J. offered to pay for the hospital stay herself, but Dr L. was adamant that it was neither possible nor necessary for the children to be hospitalized overnight.

The 2 boys had the surgery as scheduled. The surgery was uneventful, and they were observed at the hospital for 4 hours before being released. Mrs J was sent home with acetaminophen/codeine drops to alleviate the childrens’ discomfort.

That evening, Mrs J. went to sleep with the twins so that she could better monitor them. In the middle of the night, she woke up and tucked JJ in and then turned over to tuck his twin in when she realized that AJ was limp, pale, and not breathing. She screamed to her husband for help. An ambulance was called for the unresponsive toddler. Mrs J. and her husband asked a neighbor to watch the other twin, who seemed fine, and their other sleeping son, while they went to the hospital with AJ.