Santillan

V. Duke University Hospital

Shanee Thurston
Shana Reasoner
Mohammed Alanazi
March 6, 2015
HCM 388

Procedure.
a. Who are the parties?
Jesica Santillan

I.

Magdalena Santillan
Dr. Jaggers
Duke University Hospital
New England Organ Bank

Carolina Donor Services

b. Who brought the action?

Magdalena Santillan (Jesicas mother)

c. In what court did the case originate?
The case was settled outside of court between Duke University Hospital and the
family of Jesica Santillan.

d. Who won at the trial-court level?
No one won or loss, but Duke University Hospital offered Magdalena Santillan $4
million in a health care fund in Jesica's name for poor Hispanic children.

e. What is the appellate history of the case?
There was no appellate history.

II.

Facts.
a. What are the relevant facts as recited by this court?
1. On February 6, 2003, Carolina Donor Services (CDS) made the initial
offer of a transplantable heart to Duke University Hospital.

2. CDS first contacted Dr. Milano, the on-call surgeon in charge of adult
heart transplants then they were referred to Dr. Jaggers who was the
on-call surgeon in charge of pediatric heart transplants.

3. Dr. Jaggers declined for the first potential recipient, because that
patient was not ready for transplant and Dr. Davis declined due to size
mismatch.
4. CDS called Dr. Jaggers back offering the heart and lungs for Jesica. (CDS and

Jaggers discussed organ size but Jaggers does not recall blood-type matching
being discussed with them but does recall the discussion including the donor's
height, weight, organ function and cause of death. Dr. Jaggers assumed that
they wouldn't have called back and released the organs if they weren't a
match. This was a wrong assumption on his part.)

5. On February 7, 2003, the procuring team, including a Duke University

Hospital surgeon, traveled to the hospital where the donor was located.
The procuring surgeon examined the organs and judged them to be of
good quality then he called Dr. Jaggers and was directed to procure the
heart and lungs.
6. The organs were transported back to Duke University Hospital following
a delay due to bad weather.
7. Jesica Santillan was admitted to Duke University Hospital's pediatric
intensive care unit while the organ procurement team was traveling.
8. The organ transplantation operation began about 4:50 p.m.
9. When the organs arrived at Duke Hospital, the recipient's heart and
lungs were removed, and the donor organs were implanted.
10. After the organs were implanted, the surgical team received a call from
Duke's Clinical Transplant Immunology Laboratory reporting the organs
were incompatible with Jesica's blood type at approximately 10pm.
Initiation of plasm apheresis and high dose immunosuppressants were
begun in an effort to prevent organ rejection.
11. Jesica was then transferred to PICU on conventional support, which
included mechanical ventilation.
12. After the surgery, Dr. Jaggers immediately notified the family and their
supporters about the mistake in blood type matching. Then Duke
University Hospital immediately notified United Network for Organ
Sharing about the ABO incompatibility and the need for new organs for
Jesica.

13. Medical therapies continued the search for new organs from February
11 -18, 2003.
14. On February 19, 2003, in consultation with a neurologist, a CT scan was
performed to evaluate her brain. Findings did not imply irreversible
brain damage.
15. During that evening, heart and lungs of the same blood type as Jessica
were offered to Dr. Jaggers, and he accepted them for Jesica. The Duke
University Hospital transplant coordinator confirmed the blood type
compatibility with Dr. Jaggers and then subsequently with the CDS
coordinator.
16. Shortly after midnight on February 20, 2003, Dr. Jaggers discussed the
possible second heart-lung transplant with Jesica's family and
supporters who wished to proceed with the transplant. He then
received confirmation from the procuring Duke surgical team of organ
acceptability and blood group compatibility.
17. At 5:15 am 5:15 a.m., Jesica was transported to the operating room
from the intensive care unit and at 6 a.m. Dr. Jaggers and Dr. Davis
began the second transplant surgery.
18. At 10:15 a.m., the transplant surgery was completed, and Jesica was
transported from the operating room to the PICU off ECMO but on
conventional support that included mechanical ventilation.
19. On February 21, 2003 at 2 a.m., Jesica's neurologic status declined
rapidly. At 3 a.m. she underwent a CT scan of her brain that showed
evidence of bleeding and swelling. Shortly thereafter, a catheter was
placed to drain fluid and to measure the pressure in her brain. By 9 a.m.
a clinical evaluation of Jesica by the neurologist showed no brain
function.
20. At 11 a.m., Jesica's family was notified that additional diagnostic tests
would be performed. The electroencephalogram (EEG) showed no
electrical brain activity, and the perfusion scan of the head showed no
blood flow to the brain
21. On February 22, 2003, there was a neurologic examination performed on

Jesica. The results concluded that that there was no evidence of brain activity
and that this likely indicated that she had suffered brain death. A second

examination occurred at 1pm the same day which confirmed that she met the
criteria for the declaration of brain death.

22. Jesica Santillan was pronounced dead on February 22, 2003 at 1:25 pm.

b. Are there any facts that you would like to know but that are not revealed in the
opinion?
1. Was the donor igloo marked with the blood type?
2. Did it matter that 6 hours elapsed before the first donors organs were
implanted in her body?

III.

Issues.
a. What are the precise issues being litigated, as stated by the court?
There was tort of medical malpractice.

b. Do you agree with the way the court has framed those issues?
Yes I agree with how this case was settled and the effort that lawyers for Duke
University Hospital put forth in a form of a settlement.

IV.

Holding.
a. What is the courts precise holding (decision)?
Duke university hospital lost the case based on various matters regarding their
conduct at the time of the operation. To start with is in relation to release of
information. It was held that the hospital was too slow in acting.

b. What is its rationale for that decision?
The surgeon that was providing care for Jessica, as well as the rest of the hospital
personnel involved, admitted to their wrong doing/errors that cost Jessica her
life. Although the settlement process didnt seem to be easy it was still
something both parties agreed to for justice.

c. Do you agree with that rationale?
Although I feel Jessicas surgeon, as well as the medical staff present shouldve
known better, mistakes and errors do happen. I think the surgeon handled his
error efficiently and to the best of his knowledge at that time. So, no one going
to jail because a settlement was made is something I can agree with.

V.

Implications.
a. What does the case mean for healthcare today?
This case has helped healthcare grow into a more complex and ethical system.
Medical questions about mistakes in care and how to prevent them, ethical
questions about organ transplantation and end-of-life issues, mixed with

communication questions about balancing a patient's right to privacy, the needs

of the family, and the public's right to know is all covered in this issue.
Consequently, this case helped shape ethics, morale, privacy, as well as medical
safety.

b. What were its implications when the decision was announced?

Implication such as following proper procedures, as in follow ups/ confirmations

of information was indeed the biggest implication in this case.

c. How should healthcare administrators prepare to deal with these

implications?
Administrators should always hope for the best, while still preparing for the
worst. Im certain that after this case several rules were put into place to stop
things like this from happening. Being able to react quickly and efficiently, while
focusing on the patients life is a must. I think situations like this can easily be
avoided by setting up checking/confirmation systems. Using technology
(scanners, telephones, huge print, etc...) can be a simple solution to saving ones
life.

d. What would be different today if the case had been decided differently?

I believe if there was no settlement, Jessicas family may have went about this
solution differently, possibly resulting in someone going to jail and the institution
being shut down. Rules and laws, as well as ethical concerns may have never
been put in place or addressed. Consequently many more may have lost their
lives.