Hospital staff lost a piece of a patient’s skull—and then charged him for the mistake
Key Takeaways
Staff at Emory University Hospital Midtown in Atlanta lost a fragment of a patient’s skull after it was removed to reduce pressure during a brain bleed.
When staff went to retrieve the piece for reimplantation, they couldn’t find it. Several bone fragments had either incomplete or missing patient identification. After having to wait for a synthetic flap to be made and reimplanted, the patient is now suing the hospital for negligence, physical and emotional pain and suffering, and unnecessary medical bills.
Experts say that while errors like these do occur, staff communication and accountability in healthcare settings is key.
In September 2022, a patient named Fernando Cluster experienced more than he bargained for when he suffered an intracerebral hemorrhage that landed him on the surgeon’s table at Emory University Hospital Midtown in Atlanta.[] After a portion of his skull was removed in a decompressive hemicraniectomy, hospital staff lost the fragment.[][]
The initial surgery aimed to remove and store a portion of Cluster’s skull bone measuring around 4.7 inches by 5.9 inches for a future cranioplasty, during which the piece would be put back.[] However, the staff could not identify the bone flap belonging to Cluster, necessitating a synthetic flap implantation for which Cluster was billed.
Law&Crime reports that it received a neurosurgery update progress note about the second surgery via Cluster’s lawyer.[] The note confirmed what occurred in the operating room: “We inspected the freezer where bone flaps are stored and could not find a bone flap with Mr. Cluster’s patient identification. There were several bone flaps with incomplete or missing patient identification, but we could not be certain which if any of these belonged to Mr. Cluster.”
Due to the loss of the bone flap, Cluster had to wait for a new bone to be made, which he didn’t receive until November 23, 2022. Soon after the surgery, Cluster’s synthetic flap became infected, and his hospital stay was made even longer.[]
But things got worse. According to Cluster and his wife's lawsuit against Emory Healthcare, the problem was systemic: Cluster’s bone wasn’t the only one missing.[] “When Emory’s personnel went to retrieve the bone flap, ‘there were several bone flaps with incomplete or missing patient identification,’ the lawsuit states.
The lawsuit cites negligence and “extensive damages, including ongoing physical and emotional pain and suffering, and unnecessary medical bills.” The bill totals $146,845.60, which includes the bone flap, time spent in the hospital, and other related procedures.[] Cluster has also been unable to work as a result of the incident.
According to a statement made by Cluster and his wife and provided to Law&Crime by their attorney, Chloe Dallaire, of the Hornsby Law group, the couple finds the loss of the bone—and Emory’s denial of responsibility—“shocking.” The statement goes on to say that Cluster now lives in “daily fear about another infection in [his] head and medical costs.” The family wants to know if this has happened to other patients—and if the hospital gave them an explanation. The family’s goal “is to make sure this never happens to another patient again,” according to the statement.
How do errors like this occur?
Andrea Austin, MD, FACEP, CHSE, an emergency medicine physician at UC San Diego Health, tells MDLinx that while Cluster’s case is undoubtedly heartbreaking, medical errors like this do happen.
A big culprit? A culture of poor communication in the workplace. “Hospitals try to improve communication in many ways, and some frankly do a better job than others,” Dr. Austin says. “Can people speak up without fear of being humiliated, shamed, or yelled at? Unfortunately, in too many organizations, the answer is ‘no.’ While improving, surgery has a long culture of surgeons being the highest in the hierarchy and not being receptive to feedback.”
Dr. Austin provides an example of her own: “I was recently involved in a root cause analysis related to an error, and the overwhelming sentiment was that many people knew that something was wrong and didn't feel like they could speak up. We need to change the culture around speaking up and supporting those who do— the biggest thing that will decrease devastating errors like this one.”
How could the hospital have lost the bone flap? Dr. Austin has many questions: “While I don't know the specifics of this situation, was everyone well-rested? Were people working overtime? Were experienced people present or were they short-staffed and having people cover key jobs who didn't have experience with this type of procedure?”
Kanwar Kelley, MD, JD, Co-founder & CEO of Side Health, explains that there are a few ways in which hospitals store body parts. First, he says, the bone flap could be stored within a patient’s body—like their abdomen—where it is kept in a sterile environment.
Second, Dr. Kelley says, the bone flap might be kept in the hospital’s freezer, which is sterile and kept at about -80 degrees Fahrenheit. The third option, “which many hospitals don't have—like small rural hospitals—is that they mail it to a facility with a storage facility until it needs to be reimplanted. Then, that bone flap will be mailed back,” he says.
There are also several people who play a role in the surgery, he says, including the surgeon, the operating room nurses, and the many people involved in handling and processing the bone. “It changes hands many, many times, so it’s difficult to assign blame to one person without knowing [the] facts.”
What can healthcare professionals takeaway?
To build better communication, Dr. Austin cites programs like TeamSTEPPS, an evidence-based set of teamwork tools to optimize patient outcomes by improving communication and teamwork skills among healthcare teams, including patients and family caregivers. “As a simulation director, simulation is a powerful way to practice the correct protocols and procedures and, more importantly, the way we talk to one another,” she says.
An example: “We practice closed-loop communication. For instance, after saying, ‘please give epinephrine 1 mg,’ the nurse replies, ‘I am giving epinephrine 1 mg.’ It sounds simple, but these are examples of communication scripting that are important to do every day, especially in high-stress situations.”
Dr. Austin also says that compassion is key. “I'm sure the healthcare professionals involved are devastated. Nurses and physicians have very high rates of suicide. These errors are rarely related to ill intent; they are a confluence of unfortunate events, largely traced back to culture, and it's important to avoid blame and shame to get at the true root,” she emphasizes.
What this means for you After a patient came to Emory University Hospital Midtown in Atlanta in 2022 with a brain bleed, staff lost a piece of the patient’s skull after it was removed during surgery—and then billed him for the synthetic skull flap they needed to make. The patient is suing, claiming that the hospital is not taking responsibility for its actions. To reduce errors, it’s important for healthcare professionals to communicate clearly and to follow processes to a tee. It’s equally as important to own up to mistakes. As Dr. Kelley says, “Mistakes and bad things happen. No hospital or surgeon is perfect, but you want to apologize and make it up to the patient. Certainly the patient shouldn't have paid for it.”