The Medical Malpractice Case That Almost Got Away
Two excellent law firms had already turned it down. The statute of limitations was days away. We saw something in the medical records that made us take another look.
A few weeks ago, another attorney called us about a potential medical malpractice matter involving the death of a patient following a stroke. Two things about the referral stood out. The statute of limitations was roughly two weeks away. And two other law firms had already reviewed the case and declined to pursue it.
We knew both of those firms, and they are excellent. They have outstanding lawyers who do serious medical malpractice work. So the fact that both had passed gave us pause. Still, with the deadline that close, we agreed to review the available medical records on an expedited basis and make our own assessment.
What we saw made us think the case deserved a much closer look.
What we saw in the medical records
The patient had suffered a stroke and was hospitalized for nearly two weeks before being transferred to an inpatient rehabilitation hospital. According to the records, she had been receiving 40 mg of enoxaparin during the preceding hospitalization. Enoxaparin is an anticoagulant commonly used to reduce the risk of dangerous blood clots, particularly in patients who have limited mobility after a serious neurologic event. The healthcare providers at the receiving rehabilitation facility had access to the records from the prior admission.
According to the lawsuit we ultimately filed, the patient did not receive enoxaparin during her eleven-day admission to the rehabilitation hospital. During that same eleven days, the records document tachycardia, abnormally low oxygen saturation, and shortness of breath. Those findings can have many causes. In the right clinical setting, in a recently hospitalized stroke patient who had been on anticoagulation, they can also be warning signs of a developing pulmonary embolism.
On the final day of her rehabilitation admission, EMS transported her to an emergency department. She died that day. The cause was bilateral pulmonary thromboemboli, blood clots in both lungs.
Looked at together, those facts described the shape of a potentially meritorious case. A recently hospitalized stroke patient who had been receiving anticoagulation. An alleged interruption of that medication after transfer. Evolving cardiopulmonary symptoms during the eleven days that followed. And a death from bilateral pulmonary emboli on the same day she reached the ED. None of that proved negligence had occurred, and none of it justified filing a lawsuit on our reading of the records alone. It meant a medical theory needed evaluation, quickly, by physicians qualified to test it.
Two weeks changes everything
Ordinarily we would have considerably more time to investigate a case before deciding whether to file. Here, we did not. Our firm was retained with the deadline applicable to at least some of the claims approaching within days. Georgia’s medical malpractice statute of limitations is generally two years from the date of injury under O.C.G.A. § 9-3-71, with a five-year statute of repose beyond it, and a handful of exceptions that apply to minors and foreign objects. The complaint we ultimately filed invoked a separate provision of Georgia law, O.C.G.A. § 9-11-9.1, which permits additional time to file the required expert affidavit when counsel is retained shortly before the statute of limitations expires.
That procedure solved only part of the problem. We were not going to file a medical malpractice lawsuit simply to beat a deadline and figure out later whether the medicine supported it. We needed qualified physicians to review the relevant records on an expedited basis and tell us whether the concerns we had identified were medically sound.
That is where another consequence of focusing exclusively on medical malpractice became important. Over nearly twenty years, we have developed an extensive network of physicians and other healthcare professionals across virtually every medical specialty, including physicians practicing at leading medical institutions in the country. We do not start searching for medical expertise every time a new case presents an unfamiliar clinical issue. Working with physicians is what we do every day. In this case, that network let us reach the right high-level specialty physicians, get the relevant records into their hands, and secure expedited independent reviews. Their opinions were favorable and confirmed our belief that the case had merit. With that medical support, we prepared and filed the complaint before the deadline.
The complaint alleges, among other things, that the healthcare providers failed to ensure the patient received enoxaparin during her rehabilitation admission and failed to timely recognize and respond to her tachycardia, low oxygen saturation, and shortness of breath as signs of developing bilateral pulmonary emboli. It also raises claims about the facility’s systems for medication reconciliation, ordering and administration, patient monitoring, and the communication and escalation of significant changes in a patient’s condition.
Why did two excellent firms pass?
After the lawsuit was filed, we went back to the attorney who had referred the case and asked the question we most wanted answered. Why had the other firms passed?
His explanation was simple. Both were excellent firms, but medical malpractice was only one part of what they did. He believed we had identified an angle in the medical records the previous reviewers had not.
We do not tell this story because we think it makes us smarter than the lawyers at those firms. We do not. What it demonstrates is something much more mundane, and much more important: repetition matters. If you spend all day, every day reading medical records, talking with physicians, studying medical literature, questioning healthcare providers, and trying to understand how one medical event may have caused another, you develop a particular kind of pattern recognition. You get used to asking why a medication was started, why it was stopped, what happened afterward, whether a change in vital signs fits with a developing complication, and whether seemingly separate entries in the chart are actually part of the same clinical story.
Medicine itself provides the useful analogy. A cardiologist may recognize the significance of something on an EKG that another very capable physician does not immediately appreciate. A neuroradiologist may notice a subtle finding on an MRI that a physician outside that specialty could overlook. That is not a difference in intelligence or ability. It is what happens when someone encounters the same kinds of problems repeatedly. The same principle applies to lawyers. Pattern recognition is what tells us when to look harder. It is also what tells us, most of the time, when to say no.
What 100% medical malpractice actually means
We say that our practice is 100% focused on medical malpractice, but that statement matters only if the focus produces a tangible benefit for clients. This case shows what we mean. It meant that when a complicated case arrived with almost no time remaining, we were used to digging into the medicine rather than evaluating it as another personal injury claim. It meant we had standing relationships with the kinds of physicians we needed to independently test our theory, and could reach them quickly. Most importantly, years of repeatedly working through medical causation questions helped us recognize a potential connection in the records that two other very good law firms had not pursued.
None of that means every case another lawyer declines is actually a meritorious medical malpractice case. Far from it. We decline the substantial majority of the cases we review, and reasonable lawyers can reach different conclusions about the same case. This experience shows why we decided many years ago to do one thing rather than many. Our exclusive focus is not a promise of a different answer; it is a reason our review sometimes reaches one.
A serious medical malpractice case can turn on a discontinued medication, a changed laboratory value, an overlooked imaging finding, a symptom that should have prompted a different response, or a connection between events days or weeks apart. Finding those connections requires excellent medical experts. It also requires lawyers who have spent enough time immersed in medicine to know which questions to ask them. This case came to us after two excellent firms had already said no, with approximately two weeks remaining before the statute of limitations expired. We saw something in the records that concerned us, our medical experts agreed, and we acted before the opportunity to pursue the case disappeared. For us, that is what it means to say medical malpractice is not something we also do. It is all we do.
If your case was declined and you still think something went wrong
Not every case another lawyer declines has merit. Sometimes a rejection is correct. Sometimes the case is real, but too small to support the cost of litigation, too late to file, or too hard to prove without evidence the records simply do not contain. For readers in that position, there are still routes for accountability outside a courtroom, and a second legal review is only one of them.
- File a written complaint with the Georgia Composite Medical Board about the physician’s conduct.
- Report the events in writing to the hospital’s patient safety or risk management office and ask what the internal review found.
- File a patient safety event report with the Joint Commission about the accredited hospital, particularly where a system failure contributed to the harm.
- Check the medical board’s public license lookup and its published disciplinary orders, along with state court records, for prior actions against the provider. The National Practitioner Data Bank is often mentioned in this context, but its reports are confidential and closed to the public.
- Request a second legal opinion from a firm whose practice is exclusively medical malpractice, understanding that a second review is a medical review and not a promise.
A firm willing to say no on the first call is worth more than one that says yes. If the answer after a careful second look is still no, the alternatives above are how a family can still make the event count.
Questions we hear from families whose case was declined
Why won’t a lawyer take my medical malpractice case?
Usually one of four reasons. The cost of litigating a malpractice case is high, and the recoverable damages may not support the expense. The causation link between the alleged negligence and the outcome may be difficult to prove. The filing deadline may be too close for a responsible workup. Or the reviewing lawyer may believe the standard of care was met. A rejection is often correct. Sometimes it is not.
What is the hardest element of a medical malpractice case to prove?
Causation. The question is not only whether the care fell below the standard, but whether the substandard care changed the outcome the patient would have had with proper care. Separating the harm the negligence caused from the harm the underlying disease would have caused anyway is what most cases live or die on. The “but for” question, and in some cases the loss-of-chance question, is why an independent physician review matters more than a lawyer’s instinct.
How close to the Georgia deadline can a case still be filed?
Georgia’s statute of limitations for medical malpractice is generally two years from the date of injury under O.C.G.A. § 9-3-71, with a five-year statute of repose and narrow exceptions for minors and retained foreign objects. In our experience, many firms will not consider a case within roughly six months of the deadline, because there is not enough time to investigate responsibly. O.C.G.A. § 9-11-9.1 permits additional time to file the expert affidavit when counsel is retained shortly before the statute expires, but the window is real. Speak with a lawyer promptly.
Can I get a second opinion from another malpractice lawyer after being turned down?
Yes, and it is common. A responsible second-opinion review is a medical review of the records, not a promise about the outcome. Look for a firm willing to say no on the first call, willing to explain the reasoning, and willing to put contingency terms in writing. Reasonable lawyers can reach different conclusions on the same records, and a second review sometimes reaches a different answer than the first for exactly that reason.
What if the case I want to bring is against a prior lawyer, not a doctor?
That is a legal malpractice claim, not a medical malpractice claim, and it is a different area of law with different deadlines. A tort-based legal malpractice claim in Georgia carries a four-year deadline under O.C.G.A. § 9-3-25. In Titshaw v. Geer, 320 Ga. 128 (2024), the Georgia Supreme Court held that a claim for breach of a contract for legal services may instead fall under the six-year deadline in O.C.G.A. § 9-3-24 when the breach arises directly from a written contract. Which one applies depends on how the claim is framed and on the facts. We do not handle legal malpractice cases and would refer you to counsel who does.
Does contacting Davis Adams create an attorney-client relationship?
No. An attorney-client relationship is created only by a signed written agreement. Reaching out lets us evaluate whether we may be able to help. It does not commit either side to anything further.
If your case was turned down and you still think something went wrong, we can take a look
A rejection by another firm does not decide whether we can help. We review far more cases than we file, and we will tell you that on the first call. Many cases we accept are handled on a contingency-fee basis, with terms and expenses outlined in the fee agreement. If you would like us to review what happened, you can reach us through our contact page and we will talk with you about the records, the timeline, and what a careful second look would involve.
This article is for general informational purposes only and is not legal advice. Every case depends on its own facts, medical records, and expert review. Reading this page does not create an attorney-client relationship.
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