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Kohroner Chronicles: A Fatal Dose of Neglect
Not every case that comes across the autopsy table is a sensational act of violence or a calculated crime. Sometimes, it’s not neglect in the traditional sense. Sometimes, it’s ignorance, and the price is tragically high.
In this episode, we look at the death of a 14-year-old girl whose life ended not with malice, but with a misjudgment so severe, it left a trail of questions that needed answers only an autopsy could reveal.
A Special Needs Patient, A Complex Procedure
The young girl in this case lived with profound developmental disabilities. While she was 14 in age, her mental function was closer to that of a 3- or 4-year-old. Her care was a challenge, especially when it came to basic medical procedures, like dental care.
Each year, she was taken to Riley Children’s Hospital in Indianapolis, where dental work could be safely completed under general anesthesia. For such procedures, doctors opted for nasal tracheal intubation, a breathing tube inserted through the nose instead of the mouth, to allow full access to the oral cavity.
A Bleeding Complication
On her most recent visit, the procedure was routine, until the end. Upon removing the breathing tube, she suffered a significant nasal hemorrhage. Not severe enough to panic the physicians, but serious enough to warrant extended monitoring. There was concern she may have aspirated blood into her lungs.
After several hours of observation, she was deemed stable and discharged. Along with instructions, the family was sent home with Tylenol with codeine, a once-common narcotic pain reliever.
A Shocking Morning Discovery
Two days later, on a Wednesday morning, the child’s grandmother found her non-responsive and covered in blood. Emergency services were summoned, but it was too late. She was pronounced dead at the hospital. That’s when I received the call.
