Carl Beauchamp, 44, fell and hit his head. He was taken to Rhode Island Hospital where he underwent testing and was released with instructions to return if he noticed changes in his state of mind. Beauchamp, who initially was able to walk, talk and respond to commands after the fall, later became confused. He returned to the hospital.
A neurosurgery resident examined him and diagnosed his condition as post-concussive syndrome. Beauchamp was admitted to a general medical floor. During a critical 40-hour period when neuro-checks were required frequently, hospital nurses performed just one check.
Beauchamp’s condition worsened to where he responded to only painful stimuli and was unable to blink, talk and follow instructions or commands.