Zion v. New York Hospital: 1994-95

Plaintiff: Sidney E. Zion
Defendants: The New York Hospital, Maurice Leonard, M.D., Raymond Sherman, M.D., Gregg Stone, M.D., and Luise Weinstein, M.D.
Crime Charged: Medical malpractice resulting in wrongful death
Chief Defense Lawyers: Francis P. Bensel, Peter T. Crean, Luke M. Pittoni, and Keith C. Thompson
Chief Lawyers for Plaintiff: David Bamberger, Cheryl Bulbach, Judith Livingston, and Thomas A. Moore
Judge: Elliott Wilk
Place: New York City
Dates of Trial: November 10, 1994-February 6, 1995
Verdict: Doctors Sherman, Stone, and Weinstein found negligent; New York Hospital cleared of wrongdoing
Award: Doctors and hospital to pay Zion family $750,000 (later reduced to $375,000) for pain and suffering, $1 for wrongful death; no award for punitive damages

SIGNIFICANCE: The Libby Zion case led to legislation that has significantly changed the training rules for interns and resident physicians in hospitals nationwide. As a result of this case, most training programs have adopted a maximum workweek of 80 hours (formerly 100 hours), with one day off in every seven-day period. Resident doctors (the step beyond internship) must be more closely supervised, especially in the emergency room, with busy night duty relieved by "float" coverage—a system that permits one intern to catch up on sleep while another covers for him or her—and with fewer patients cared for by a single resident. The Zion case stands also as an example of how one person can compel a long-established institution—the medical infrastructure that encompasses hundreds of hospitals—to re-examine and overhaul its customs and practices.

On Thursday, March 1, 1984, Libby Zion, an 18-year-old freshman at Bennington College in Vermont, had been living at home in New York City for two months under the college's work-study program.

During the previous January, at the suggestion of her mother, Elsa, Libby had begun seeing a psychiatrist. He had prescribed an antidepressant drug, Nardil.

On this particular Thursday, complaining of a cold, Libby visited her pediatrician, who prescribed an antibiotic, erythromycin. Libby then saw her dentist, who extracted a decayed eyetooth and gave her Percodan pills to help alleviate any resulting pain.

The next day, not feeling well, Libby went home early from work. By that evening, she had a fever, and by Sunday afternoon she complained she was "burning up inside." Her mother took her temperature and found that it was 102. Elsa gave her daughter alcohol rubs and checked with the pediatrician, who said to continue the antibiotic. That evening, Libby seemed better and her parents went out to a party.

Around 10 p.m., Libby's brother Adam called his parents asking them to come home, saying Libby was "really bad." They found her skin flushed and her eyes dilated and apparently rolling. Her father, Sidney Zion, phoned Dr. Raymond Sherman, who advised taking Libby to the emergency room at New York Hospital.

There, Dr. Maurice Leonard, a second-year resident in charge of the emergency room, took a full medical history from Libby and her mother. When her parents were out of earshot, he asked Libby if she used marijuana. She said she often did, but not on that day. He asked about other medicines or illegal drugs, including cocaine. She denied taking any. The doctor and the emergency room nurse performed a two-hour evaluation including a chest X ray, cardiac exam, blood tests, and urinalysis. To help control her temperature, they gave her fluids through an intravenous (IV) line. They noted Libby's thrashing, compulsive arm and leg movements alternating with moments of calm. They recorded her dehydration and her temperature climbing to 103.5. Finally, Dr. Leonard turned his patient over to Dr. Luise Weinstein, the intern on duty on the private floors, and her supervisor, Dr. Gregg Stone, the second-year resident on duty. The doctors agreed on a tentative diagnosis of "viral syndrome" and admitted Libby to a semiprivate room.

Libby's agitated shaking continued. Twice her thrashing disconnected her IV. At 2:45 a.m., however, her parents, sensing that she was being cared for, went home.

At 7:45 a.m., Dr. Sherman called Sidney Zion and asked him to come to the hospital at once. While Sidney hurried to get ready, Elsa called Dr. Weinstein and learned that Libby had died at 7:30 that morning.

Formal Complaint Served

Formerly an assistant U.S. attorney, Sidney Zion had been a legal correspondent for the NAew, York Times for five years in the 1960s. Since then he had written numerous newspaper and magazine articles.

On July 17, 1985, a formal complaint charging gross negligence was served by "Sidney E. Zion, as Administrator of the estate of Libby Zion, deceased, Plaintiff, against The New York Hospital, Raymond Sherman, M.D., Maurice Leonard, M.D., Luise Weinstein, M.D., and Gregg Stone, M.D., Defendants."

In addition to the complaint, Zion pressed New York County (Manhattan) District Attorney Robert Morganthau to indict the doctors for criminal negligence. On November 20, 1986, a grand jury report "concerning the care and treatment of a patient and the supervision of interns and residents at a hospital in New York County" made history as the first such report in the annals of medicine—without naming Libby Zion or New York Hospital. According to the report, specifically in this case:

no attending physician had performed an examination;

only an intern and junior medical resident had supervised the patient's admission;

those two duty officers had each been working for 18 hours at the time of admission (2:00 a.m.);

physical restraints had been applied without an examination by a physician; and

Demorol had been administered without knowledge of earlier treatment with Nardil.

Making broad recommendations, the report urged legislation to overturn counterproductive medical procedures as:

hospitals interpreting "inadequate and ill-defined laws" to permit resident doctors to act unsupervised;

hospitals overworking their residents, keeping trainee doctors on duty as long as 36 hours without relief;

residents (known as PGY-3s, for postgraduate year) being allowed to serve in emergency rooms;

interns (PGY-ls) and residents (PGY-2s) not being supervised in person by PGY-3s.

The report revealed that, after Libby's parents went home, she was given Demorol and Haldol to help control her agitated movements and was restrained in a Posey jacket (a vestlike garment that leaves the arms free). The report also noted the autopsy's report of trace amounts of cocaine found in Libby's nose.

The autopsy had concluded that Libby had died of bilateral bronchopneumonia caused by a virus or bacteria, adding that she collapsed after receiving Demerol and Haldol.

On March 12, 1987, the New York State Department of Health fined New York Hospital $13,000 for "woeful" treatment of Libby Zion. Admitting that it had not given her appropriate care, the hospital agreed to adopt a remedial program that included monthly evaluation of emergency room procedures.

In April, the New York State Board for Professional Medical Conduct, responding to persistent demands by Sidney Zion, held the first of 30 hearings charging Doctors Weinstein and Stone with gross negligence and/or gross hearings charging Doctors Weinstein and Stone with gross negligence and/or gross incompetence. After interviewing 33 witnesses over the course of two years, the board unanimously dismissed all charges. The New York State Board of Regents, however, reversed the verdict but concluded that a "censure and reprimand" was adequate punishment. Ultimately the New York State Supreme Court Appellate Division cleared the doctors of the formal censures.

Conflicting Trial Testimony

As the trial opened on November 10, 1994, plaintiff attorney Thomas A. Moore asked for $2 million for Libby's pain and suffering, plus $1 for her wrongful death. He cited a litany of reasons for punitive damages, including:

Dr. Sherman, as attending physician, had failed to appear at the hospital;

the patient's fever was ignored;

her vital signs were not monitored properly;

she was administered Demorol even though her current medications included Nardil;

she was held in restraints;

Dr. Weinstein did not respond to calls from nurses for assistance.

The defense admitted that administering Demerol had been wrong, but insisted that had not caused Libby's death. Eleven hospital witnesses testified that Libby's care had been appropriate.

Judge Elliott Wilk presided, as plaintiff lawyer Moore debated defense attorney Frank Bensel over whether Libby's agitated condition had begun at home or in the emergency room. Dr. Charles Wetli, the hospital's expert in forensic pathology, testified that Libby did not have pneumonia; but its expert in infectious diseases, Dr. William McCormack, testified that early signs of pneumonia were present. The plaintiff's star witness, Dr. Harold Osborn, director of emergency services at the South Bronx's Lincoln Hospital, accused the doctors of doing virtually everything wrong. In an intensive debate over whether Libby's infection had been due to viral or bacterial causes, Dr. Osborn said her white blood cell count indicated that bacteria were present even though none appeared in her urine.

Plaintiff attorney Moore insisted that the combination of Nardil, the antidepressant drug Libby had been using since January, and Demerol, administered in the hospital after the Zions went home, had brought about her death. Defendant Dr. Luise Weinstein admitted that she had failed to notice the phrase "death can result" while checking the Physicians' Desk Reference for information on the drug combination. Defendant Dr. Sherman testified that a cocaine-Nardil reaction was a possible cause of her death. And the hospital's expert in standard of care, Dr. Robert Glickman, testified that the cause of Libby's death "was operative before she entered the hospital" because "the events in the hospital are not adequate to explain why she died."

Finally, defendant Dr. Gregg Stone testified, "Based on the evidence and what we've learned over the years, I think cocaine is what killed this poor girl."

Further testimony addressed the issue of whether the intern's and residents' lack of sleep contributed to Libby's death. A defense witness and sleep expert, Dr. Michael Thorpe, said Dr. Weinstein had not been sleep deprived, while the plaintiff's expert witness Dr. Merrill Mitler observed that sleepdeprived doctors are likely to ignore patients' warning signs and may not check medical literature.

Both Demerol and Doctors Blamed

The jury deliberated for four days. Finally it found that Dr. Stone and Dr. Weinstein ordering the administration of Demerol had been a proximate cause of Libby's death. The jury further found that the intern and two residents had been negligent in administering it. Blame was also put on Dr. Weinstein for not personally checking on the patient when called by a nurse at 4:30 a.m., and for not consulting more experienced doctors at that time. The jury found the hospital negligent regarding the workload assigned to Dr. Weinstein. It found that Libby had ingested cocaine at some time on March 4, 1984, and had been negligent in giving her medical history. Because of this, the jury unanimously decided she had been 50 percent responsible for her death, and the hospital also 50 percent responsible.

The jury also said the hospital's system of training and supervising young doctors did not depart from accepted medical practice. It awarded no punitive damages, but ordered the doctors and hospital to pay $750,000 to the Zion family for pain and suffering—plus the $1 for wrongful death. On May 1, however, Judge Wilk ruled that the jury had improperly heard evidence of the cocaine use and threw out the blame allocated to Libby Zion. However, he lowered the total award amount to $375,000.

—Bernard Ryan, Jr.

Suggestions for Further Reading

Asch, D.A., and R.M. Parker. "The Libby Zion Case: One Step Forward or Two Steps Backwxard?" New England Journal of Medicine, (March 24, 1988).

Duncan, David Ewing. Residents: The Perils and Promise of Educating Young Doctors. New York: Scribner, 1996.

Gilbert, Sandra M. Wrongful Death: A Medical Tragedy. New York: Norton, 1997.

Harr, Jonathan and Marty Asher, eds. A Civil Action. New York: Random House, 1996.

Hinckle, Warren and John J. Simon. Do No Harm: The Libby Zion Case: How Doctors Killed Her and Then Blamed the Victim. New York: Argonaut Press, 1996.

Macklin, Ruth. Enemies of Patients: How Doctors Are Losing Their Power and Patients Are Losing Their Rights. New York: Oxford University Press, 1993.

Nuland, Sherwin B., M.D. How We Die. New York: Knopf, 1994.

Robins, Natalie. The Girl Who Died Twice: Every Patient's Nightmare —The Libby Zion Case and the Hidden Hazards of Hospitals. New York: Delacorte, 1999.

Werth, Barry. Damages: One Family's Legal Struggles in the World of Medicine. New York: Simon & Schuster, 1998.

Zion, Sidney. Trust Your Mother But Cut the Cards (fiction). New York: Barricade Books, 1993.