Case Study: One Small Cut that Killed

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Case Study: One Small Cut that Killed

By Lindsay Bohonik

Dr. Contadina is a primary care physician in a Metropolitan area at a large, not-for-profit, integrated health care system. On average, she sees several patients a day from a variety of backgrounds who come in with an assortment of conditions, injuries, and ailments.

One day, a patient comes to see her complaining of ankle pain on his right leg. The patient is a farmer and says that he fell while he was taking care of his chickens in the chicken coup. He has some cuts and bruises on either leg, complains of a swollen right ankle, but appears to be fine otherwise. Dr. Contadina instructs him to purchase an air cast at a pharmacy along with some ibuprofen and to take it easy. Dr. Contadina returns to seeing other patients and Joe goes home.

Three days later Joe is admitted to the emergency room. He has low blood pressure, a fever, extreme shaking, an irregular heartbeat, and is very agitated. After removal of the air cast, the nurses notice a cut that has become infected on his left leg (the opposite of the leg with the swollen ankle). Joe’s condition continues to worsen and he eventually goes into Septic shock. After two days in the ICU, Joe dies of complete organ failure.

The family wants answers, and so far, all they know is that he came in with one small cut and suddenly died. The hospital is pressuring Dr. Contadina to apologize in hopes of mitigating some legal trouble. Dr. Contadina is afraid that if she admits that there was any chance she made a mistake, that she’ll be in bigger trouble- both legally and professionally. She is very afraid of what her colleagues and patients will think if she admits that she made an error.

Questions for discussion

  • As the administrator of the hospital, what do you do?
    • Do you require that Dr. Contadina apologize to the patient’s family and explain to them what went wrong?
    • What are the risks to doing so?
  • Does Dr. Contadina have an ethical obligation to admit error?
    • What are the possible benefits to admitting fault?
  • What could the hospital and/or Dr. Contadina (or any physician) have done differently?
  • Was this a preventable mistake?


  • This is adapted from a similar case (McCourt v. Abernathy, 457 S.E.2d 603 [S.C.1995]), and the recent movement towards hospitals and physicians accepting greater responsibility for medical errors.
  • Evidence has recently indicated that there are two main reasons for why patients sue: 1) Because they feel like they have been wronged or disgraced and, 2) To get answers about what happened. For many patients and/or families, pursuing legal action is the only way in which they can get information regarding what happened.1
  • Thus, there has been an indication that if patients feel that their physician expresses remorse over the mistake, and they are explained to why it happened, it can potentially reduce liability.

1 Hall, M.A., Bobinski, M.A., & Orentlicher, D. (2008). Medical Liability and Treatment Relationships (p.274-303, 2nd Ed). New York: Aspen Publishers

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