Kendra M. Profumo Simple surgery results in perforated uterus, bowel, sepsis and continuing poor health

Your Name: Michael J. Profumo

Patient’s Name/Relationship: Kendra M. Profumo, daughter in law

City/State: Davis, California

When did event occur (what year)? April-September 2014; continuing to the present

Where did event occur? Acute Care General Hospital

What type of medical harm did you experience or witness? Surgical Error

Please describe what happened. Patient underwent a minor women’s health procedure as an outpatient at Sutter Davis Hospital in April 2014. The procedure perforated the uterus, which was discovered and treated. However, the bowel was perforated in two places at the same time, which was not discovered. The patient was sent home that day and experienced horrific pain that night. The patient called the night line for her PCP and was advised that it was just pain from the air injected into her abdomen during the procedure, which was grossly in error. The next day the patient was admitted to Sutter Davis Hospital, through the ER. The patient lay in a bed screaming in pain for over 24 hours until her PCP happened to be in the Hospital and came by to see her and immediately called for the Hospitalist, which led the Hospitalist to order emergency surgery. Where was the Hospitalist during all of the time the patient lay in bed screaming in pain? The patient had severe sepsis and nearly did not survive. The patient was in the Hospital for eight days and was discharged prematurely as the infection was still in her body; she was readmitted to the Hospital 19 days later and stayed for another five days to clear up the infection. My opinion is that she was discharged early due to the Hospital mistakenly thinking her insurance was expiring on the day she was discharged. Later in the 2014 year, the patient had to have another surgery to correct the original incision. Finally in 2015 the patient had to have yet another surgery to treat the incision and scar tissue, which was done outside of the Sutter Health system due to safety concerns. Today, the patient still suffers from the aftermath of severe sepsis, which may be with her for the rest of her life. Litigation was not pursued as medical malpractice cases in California are an exercise in futility given the current laws in the State–to the detriment of those patients having legitimate claims. The insurance carriers for both Sutter Health and the individual physicians involved, as well as the Medical Board of California, determined the actions of those involved were within the “Standard of Care”, which should be of concern to everyone in this State. There was a legal dispute between Sutter Health and the health insurance carrier for the patient. The health insurance carrier determined in their review it was a case of malpractice and some misleading billing issues. The case was ultimately settled out of court and the patient paid no medical bills relating to any of these issues.

What was the outcome of the medical harm issue? Serious or life-threatening injury