A number of factors may contribute to a person dying unexpected following release home from the Emergency Department.


Recurrent themes reported by Sklar et al:

(1) atypical presentation of an unusual problem

(2) chronic disease with end-stage decompensation

(3) presence of abnormal vital signs (see below)

(4) mental disability, psychiatric problem and/or substance abuse (unwilling to return for worsening symptoms)


Abnormal vital signs included:

(1) pulse > 99 OR < 60 beats per minute

(2) systolic blood pressure > 179 OR < 90 mm Hg

(3) diastolic blood pressure > 109 mm Hg

(4) respiratory rate > 24 OR < 12 breaths per minute

(5) body temperature > 37.9°C (100.2°F) OR < 35°C (95°F)

(6) oxygen saturation < 90%


Additional factors might include:

(1) The patient was physically unable to return for worsening condition.

(2) There was progression of a condition not detected in the ED (like subarachnoid hemorrhage).

(3) The patient did not want to stay.

(4) The healthcare provider was inexperienced or made an error.


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