Undiagnosed Bronchoscopy Complication Resulting in Death
On May 30, 2025, an Allegheny County jury awarded $5.25 million to the family of a 67-year-old woman who died from complications following a routine outpatient bronchoscopy at Jefferson Regional Medical Center.
After experiencing bouts of multi-focal pneumonia over several months, Darlene Jury presented to Jefferson Regional Medical Center on August 18, 2021 for an outpatient bronchoscopy, performed by pulmonologist, Dr. Christian Kyung. While Darlene used 2L of oxygen at home, her admission assessment noted her baseline oxygen saturation was 97% on room air approximately one hour before the procedure.
The bronchoscopy was performed without complication per the operative report. After the procedure, Darlene was transferred to the Post-Anesthesia Care Unit (PACU) Phase 1 at approximately 8:57 a.m. to recover from the bronchoscopy. While there, she underwent a chest x-ray which revealed an airspace opacity in the right lower lung.
While in PACU Phase 1, Darlene was receiving supplemental oxygen via face mask and nasal cannula. At approximately 9:15 a.m., a nurse removed Darlene’s supplemental oxygen, and her oxygen saturation dropped to 84%, indicating that she was unable to sufficiently oxygenate without supplemental oxygen. At 10:06 a.m., Dr. Kyung placed a discharge order noting that Darlene was stable for discharge despite her complaints of continued shortness of breath, chest pain, and coughing bloody sputum, all of which Dr. Kyung informed her was normal. At approximately 11:06 a.m., anesthesiologist, Dr. Wen Xu, entered a discharge order indicating that Darlene was stable for discharge.
While in PACU Phase 1, Darlene’s oxygen saturation continued to decline despite increasing supplemental oxygen. For instance, at 11:15 a.m., she required 3L of oxygen via nasal cannula to maintain 90% saturation, and at 11:30 a.m., she required 4L of oxygen via nasal cannula to maintain 90% saturation. At 11:57 a.m., Darlene was transferred from PACU Phase 1 to PACU Phase 2 despite her worsening oxygenation.
While in PACU Phase 2, nurses observed Darlene pointing to her chest in pain and she continued to require supplemental oxygen to maintain her saturation at 90%. Darlene’s vital signs from 12:30 p.m. – the last set of vitals taken prior to her discharge home at 1:01 p.m. – indicated that she was oxygenating at 90% on 4L of supplemental oxygen. The nurses caring for Darlene never notified Dr. Xu or Dr. Kyung of Darlene’s worsening oxygenation. She was discharged home at 1:01 p.m. despite her increasing need for oxygen and worsening oxygen saturations.
Darlene’s ex-husband picked her up from Jefferson Regional Medical Center shortly after 1 p.m. He reported that the nursing staff brought Darlene to his car with a hospital oxygen canister despite Darlene not needing supplemental oxygen upon arrival to the hospital.
Later that evening, Darlene complained of chest pain and shortness of breath. She went to bed wearing oxygen. Her mother discovered her the next morning deceased in bed. An autopsy revealed a 2mm perforation of Darlene’s right lower lung which led to a massive internal bleed.
The hospital had policies in place which contained criteria that must be met in order for a patient to be safely discharged home. The medical providers caring for Darlene violated several different aspects of the policy which led to her unsafe discharge home. Specifically, the Aldrete score, a critical scoring system used to assess when a patient is sufficiently stable to be safely discharged from the PACU, was not properly calculated and communicated to the nurses and physicians caring for Darlene. Further, the policy required Darlene’s oxygen saturation at discharge to be the same as her pre-anesthesia baseline of 97% room air. However, at the time of discharge, Darlene was on 4L of oxygen and was only oxygenating at 90% despite breathing room air upon arrival. Darlene’s declining oxygen saturation and increased need for supplemental oxygen should have prompted further evaluation and investigation into the concerning oxygenation trends.
While at trial, several nurses testified that they violated the hospital policies and breached the standard of care. A corporate representative from Jefferson Regional Medical Center testified that the hospital does nothing to ensure its policies are being followed until after something tragic happens. The jury found that the hospital’s negligence was the factual cause of Darlene’s death and awarded her family $5,000,000 for the Wrongful Death Action and $250,000 for the Survival Action. This case is an example of the tragedy that can occur when hospitals fail to sufficiently train staff on patient safety policies and fail to ensure the patient safety policies are being followed.