The missed bilirubin test: Cal Sheridan's story

Summary

Cal Sheridan was born a healthy baby boy in March 1995 in Boise, ID. Hospital staff noticed that Cal looked jaundiced at 16.5 hours old, but a bilirubin test was not done. Staff again reported Cal’s visible jaundice at 23 hours old, but a bilirubin test was not done then either. Despite being described as having head-to-toe jaundice, Cal was discharged from the hospital when he was 36 hours. A bilirubin test was not done.

Cal’s parents, Sue and Pat Sheridan, were assured that newborn jaundice was normal and were told not to worry.

In the afternoon of Cal’s sixth day, while still in the hospital, Cal cried in a high pitch, was experiencing respiratory distress, and started to arch his neck. Unbeknownst to the Sheridans, all of these are signs of kernicterus—brain damage caused by jaundice. While the health professionals at the hospital noted these symptoms, they missed the connection and did not diagnose kernicterus.

Finally, at 18 months of age Cal was diagnosed with a classic case of kernicterus. Sue and Pat learned that Cal had been suffering from brain damage secondary to jaundice since his early days of life. “I will be haunted by that memory and my failure to protect him forever,” says Sue.

“Cal’s brain damage was totally preventable and is the result of a series of failures in our medical system,” says Sue. “I am incapable of explaining to my son the justification for his disability. It is precisely what motivates me to advocate for change in our healthcare system.”

Further reading on the hub:

This year’s World Patient Safety Day on 17 September 2024 (WPSD 2024) is focused on the theme “Improving diagnosis for patient safety”. Find out more.