Case study: Alleged failure to perform a complete assessment and provide parental notification of a potential head injury resulting in permanent neurological injury.
Summary
Medical malpractice claims may be asserted against any healthcare provider, including nurses. The insured in this case was a registered nurse (RN) who held a Bachelor of Science in Nursing degree. At the time of the incident, the RN was working as an employee of a school district in a public elementary school. She had over 20 years of experience as a school nurse.
An 8-year‑old female student with no significant medical history presented to the school nurse (RN) from physical education class complaining of a headache. The student denied blurred vision, dizziness, or other symptoms. The RN initially thought that the student may have been injured in physical education class, however, the student denied any such injury.
The RN conducted a comprehensive assessment which revealed a normal neurological exam and no physical evidence of head trauma. She observed the student in the health office for thirty minutes and concluded that the student likely had a mild, transient headache and that no head injury had occurred. She administered Tylenol per school policy and released the student back to class. The RN attempted to contact the student’s parents to report the visit; receiving no answer, she left a voicemail but did not receive a return call. The RN documented the student’s presenting complaints, physical assessment and attempt to contact the parents in the paper healthcare information record. Later that day, the RN re-assessed the student. The student reported that she was feeling better and that the headache had subsided. The RN sent a note home with the student to inform the parents of the nursing visits and retained a copy of the note in the healthcare information record. She also documented the re-assessment indicating that the student denied any further complaints.
Two days later, the student presented to the nurse’s office with a complaint of oral bleeding, which she reported had begun earlier that morning before school. The student indicated that her mother had already scheduled a dental appointment for the following week. Upon examination, the RN noted minimal bleeding along the gum line and no other complaints. Based on the assessment and the pending dental appointment, no further action was deemed necessary. The RN notified the parents via a written note and documented the encounter, assessment, and plan in the healthcare information record.
Over the following two days, which fell on a weekend, the student developed a severe headache and hematuria and was admitted to the hospital where she was diagnosed with acute idiopathic thrombocytopenic purpura (ITP) and a critically low platelet count of 4,000. She was transferred to the intensive care unit and, within a 24‑hour period, experienced a massive intracranial hemorrhage (ICH), resulting in permanent neurological impairment. The student underwent neurosurgical procedures to drain the bleeding and was discharged to a rehabilitation center. It was concluded that she would not be able to independently perform activities of daily living and would require lifelong care.
The parents informed the school principal of the student’s condition and their belief that the ICH was caused by a head injury sustained during a previous physical education class. The principal conducted an internal investigation and requested written summaries from the RN and the physical education teacher detailing their interactions with the student on the dates in question. The RN documented that the student was seen by her for complaints of a headache and that the student specifically denied having a fall or being injured at school. The physical education teacher reported no recollection of any incident involving a head injury relative to this student. Based on the documented findings by the RN and teacher in the school investigative report, the principal concluded that no injury had occurred on school grounds.
Risk Management Comments
Eight years later, a lawsuit was filed by the parents (plaintiffs) naming the RN, the school district and the physical education teacher. The plaintiffs asserted the following claims against the RN:
- Failure to assess/recognize symptoms of a potential head injury: The plaintiffs maintained that the student fell or was struck by a ball during gym class and that the RN failed to identify head trauma and to follow the school district’s head injury protocol.
- Failure to communicate: The plaintiffs denied receiving the notes from the RN and alleged that the RN failed to notify them about the head injury. They maintained that they would have sought medical attention earlier, and that this lack of information resulted in a delayed diagnosis of an intracranial hemorrhage.
The plaintiffs claimed that the school district failed to ensure compliance with its head injury policies and that the physical education teacher did not properly supervise the class. They contended that the intracranial hemorrhage was directly caused by a head injury that occurred in the school. The plaintiffs’ nursing expert opined that the RN failed to meet the standard of care by failing to identify signs of an impending ICH and failed to communicate directly with the parents about the headache.
Defense Experts:
The defense team was able to secure supportive nursing experts given the comprehensive documentation of the RN’s assessment and interactions with the student as well as documentation of the written communications sent home to the parents. There were also supportive experts regarding the causation of the cerebral hemorrhage. A hematology expert opined that the cause of the acute ICH was severe thrombocytopenia from ITP (platelets 4k), with petechiae, ecchymosis, gum bleeding, and hematuria —all risk factors for spontaneous ICH. The chronology of symptoms and clinical presentation supported the ITP causation and pointed away from a traumatic injury etiology. Defense experts in neurosurgery opined that if there was traumatic head injury that occurred at school, it would have manifested in closer proximity to the ICH.
Discovery revealed potential contributory negligence related to the parents’ delay in seeking medical care as the student’s condition worsened over the weekend. Ultimately, a strategic decision was made not to pursue this issue.
The plaintiffs dismissed the physical education teacher from the lawsuit, as no objective evidence supported the claim that inadequate supervision had occurred.
Resolution
The case carried a significant exposure for an excessive jury verdict due to the plaintiff’s permanent neurological injuries and sympathetic circumstances. However, the RN was dismissed from the matter without an indemnity payment, largely attributable to her complete, detailed documentation of patient assessments and monitoring.
Total Incurred: More than $100,000 in defense costs. Defense costs were driven primarily by an extended discovery period and multiple procedural and legal delays throughout the case.
(Figures represent only the outcome for the insured RN and do not include any payments that may have been made by or on behalf of other involved providers or companies.)
Risk Management Recommendations
- Document all discussions with students/parents and actions taken, including any treatment recommendations that were provided. Objective and concise documentation is essential for both continuity of care, as well as for the defense of a potential malpractice claim. A comprehensive healthcare information record is critical to any legal defense.
- Conduct comprehensive assessments and re-assessments of students with suspected head injuries in accordance with school district and professional industry standards. According to the National Association of School Nurses (NASN), “the registered professional school nurse provides leadership/care coordination in collaboration with the school-based team to manage student concussion. The school nurse has the healthcare knowledge and skills to provide concussion prevention education to parents/guardians, students, and school staff; identify suspected concussions; and help guide students as they return to academics/learning, physical activities, and sports.”
- Educate the student, parent and/or responsible party about the need for follow up or ongoing monitoring, medication regimens and screening procedures, and document all discussions. Place a copy of written instructions in the school healthcare information record.
- Engage in continuing education and pursue specialty certification to maintain nursing assessment skills and up-to-date knowledge to treat the wide range of healthcare needs of a student population.
- Ensure proper access to school nursing care in alignment with the National Association of School Nurses (NASN) Professional Practice Documents and Position Statements. The NASN advocates for at least one full-time school nurse (RN) in every school.
- Assess the student’s/family’s health literacy level to ensure an adequate understanding of their role in the treatment plan. Consider using the “teach-back” method for communicating instructions about the treatment plan, using open-ended questions to prompt the student/parents to explain critical information back to you, in their own words, to verify understanding.
- Follow established school district protocols for contacting parents and document the date/time, number called, message content, and outcomes (left voicemail, no answer). Maintain copies of all written communications to parents.
Disclaimers
The information, examples and suggestions presented in this material have been developed from sources believed to be reliable as of the date they are cited, but they should not be construed as legal or other professional advice. CNA, Aon, Affinity Insurance Services, Inc., NSO, or HPSO accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All products and services may not be available in all states and may be subject to change without notice. Certain coverages may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds, and insureds are therefore not protected by such funds. The claims examples are hypothetical situations based on actual matters. Settlement amounts are approximations. Certain facts and identifying characteristics were changed to protect confidentiality and privacy. Any references to non-CNA, non-Aon, AIS, NSO, and HPSO websites are provided solely for convenience, and CNA, Aon, AIS, NSO and HPSO disclaim any responsibility with respect to such websites. “CNA” is a registered trademark of CNA Financial Corporation. Certain CNA Financial Corporation subsidiaries use the “CNA” trademark in connection with insurance underwriting and claims activities. This material is not for further distribution without the express consent of CNA. Copyright © 2026 CNA. All rights reserved.
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Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc., a licensed producer in all states (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc., (CA 0G94493), Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency.