A Virus or a Fatal Oversight? The Death of a 20-Year-Old After an E.R. Visit

Sam Terblanche, a vibrant 20-year-old, walked into a bustling emergency room with symptoms that his doctors dismissed as "just a virus." Days later, he was dead, leaving his family and a reeling medical community to question how such a tragedy could unfold. The case raises critical concerns about the immense pressures on emergency departments and their capacity to detect rare, life-threatening conditions amidst a sea of more common illnesses. Terblanche's death has become a focal point in a national conversation about diagnostic errors, the systemic failures that enable them, and the devastating human cost of a healthcare system stretched to its limits.

ycombinator.com reported, The narrative of Sam Terblanche's final days is a harrowing account of a medical journey that went terribly wrong. After being initially diagnosed and sent home, his condition rapidly deteriorated. By the time he returned to the hospital, it was too late. The actual cause of death was sepsis, a catastrophic immune response to an infection that had been missed during his first visit. This outcome has cast a harsh spotlight on the diagnostic process in high-pressure environments.

An automated alert for sepsis was even triggered by his vital signs during his care, but due to a combination of factors including a novice physician's unfamiliarity with the hospital's information system, the warning did not lead to a change in course. The incident underscores a grim reality: even with modern technology and protocols, the combination of overcrowded E.R.s, staff fatigue, and cognitive biases can lead to fatal oversights.

• Timeline of a Tragedy: Sam Terblanche first presented to the emergency department with a high fever and a rapid heart rate. According to his medical chart, which was 51 pages long, an automated alert for sepsis was triggered by these symptoms. Sepsis is a life-threatening condition that requires rapid intervention.
• However, a junior doctor, reportedly on his first patient that triggered the sepsis protocol, struggled to navigate the hospital's electronic ordering system. A more senior resident showed him how to proceed, but crucial steps were delayed or missed. The patient's chart contained numerous contradictions, such as noting a heart rate of 126 while also being marked as "normal," and vital signs that were ordered but never taken.
• The Missed Diagnosis: Sepsis: Sepsis was the ultimate cause of death, a condition that is notoriously difficult to spot as its early symptoms mimic less severe illnesses like the flu. It is one of the top 15 diseases associated with serious misdiagnosis-related harm in emergency departments. The failure to diagnose it can drastically reduce a patient's chance of recovery.
• In Terblanche's case, an automated sepsis warning was triggered but did not lead to the necessary immediate treatment with strong antibiotics.
• Systemic Pressures and Diagnostic Errors: Emergency rooms are high-pressure environments where diagnostic errors can have devastating consequences. Overcrowding leads to rushed evaluations, reduced time with each patient, and an increased risk of mistakes like misreading symptoms.
• A 2022 systematic review found that an estimated 5.7% of all E.R. visits involve a diagnostic error, which could translate to over 7 million errors annually in the U.S. Staff fatigue and stress from long shifts further compound the problem, affecting clinical decision-making and the quality of care.
• Cognitive Bias in Medicine: Experts suggest that cognitive errors, particularly in cases with "atypical" presentations, are a major factor in misdiagnoses. This can include "anchoring bias," where a physician holds onto an initial impression (like a common virus) and fails to consider other possibilities, even when new information arises.
• In malpractice claims related to diagnostic errors, failures in clinical judgment are implicated in nearly 90% of cases.
• The Role of Hospital Information Systems: The New York Times article highlights how hospital information systems, designed to improve safety, can sometimes create obstacles. In this case, the sepsis alert pop-up on the computer screen reportedly blocked the physician's progress, and the immediate goal became navigating the software rather than re-evaluating the patient's condition.
• This points to a critical need for better design and training to ensure these digital tools aid, rather than hinder, clinical workflow in critical moments.
• The Aftermath and Broader Implications: The autopsy suggested a possible cause of death as multisystem inflammatory syndrome (MIS). Terblanche's death is a stark reminder of the potential for serious harm from diagnostic errors, which are estimated to cause over 350,000 serious harms, including permanent disability or death, in the U.S. each year.
• The case has fueled calls for systemic changes to address E.R. overcrowding and to improve diagnostic processes, potentially through national performance dashboards and other policy levers. For patients and their families, it serves as a painful lesson to advocate for themselves and to ask physicians directly, "Could it be something else?"