Excerpt & Case Study: Medical Failures That Cause LIS

Locked-in syndrome, a condition in which a person remains fully conscious and aware while almost entirely paralyzed, is rare. The medical failures that lead to it are not. In our new book, we trace how a handful of missed signals in an emergency room can produce one of the most devastating outcomes in medicine. A story (and the commentary we offer) featured in our new book, Locked-In Syndrome: A Guide for Families and Caregivers, clearly illustrates how medical failures can result in this condition.

Jonathan’s Story, Chapter 3

“Jonathan’s father, Jack, keeps his garage stocked like a miniature hospital supply depot. Shelves are lined with medical equipment and consumables. Extra tubing. Suction supplies. Wipes. Gloves. Monitors. Lifts. As he walks through it he says simply, ‘We created an ICU, honestly.’ Not for strangers. For his son.

Back in October 2015, Jonathan was a young, active Georgia man. He played nearly every sport. He was always moving. One day, he became dizzy and disoriented during a chiropractic appointment. Over time he grew less and less responsive. His family rushed him to the emergency room at North Fulton Hospital.

In the ER, two physicians evaluated him. An emergency doctor and a radiologist. They ordered tests. They reviewed scans. They spoke with a consulting neurologist. But they did not connect the dots. They did not treat him as a stroke alert. They did not tell the neurologist that Jonathan had seen a chiropractor that day. They did not mention that he had what looked like a second seizure-like event. The radiologist missed important information on a scan.”

Jonathan was having a stroke. A serious one. It went undiagnosed and untreated for twelve critical hours.”

Medically, this timeline matters enormously. Ischemic stroke treatment operates on a clock measured in minutes:

• tPA is generally only effective within a 3-to-4.5-hour window from symptom onset.
• Mechanical thrombectomy has its own longer, but still limited, window.

At 12 hours, both options are typically off the table. What’s notable here isn’t one catastrophic decision but a chain of smaller ones: a chiropractic visit not relayed to the consulting neurologist, a second neurological event not flagged, and a scan finding not caught. Each omission on its own might not change an outcome. Stacked together, in a case involving a young, otherwise healthy patient whose presentation didn’t fit the classic stroke picture, they closed the window for treatment entirely.

Legally, this pattern of omissions is significant for a different reason: it’s what elevated the case from ordinary negligence to a finding of gross negligence.

Ordinary malpractice claims typically require showing that a provider’s conduct fell below the accepted standard of care. Gross negligence is a higher bar; it generally requires a showing of reckless disregard, not just an isolated error in judgment. A jury and appellate court affirming that standard in this case signals that the failures were not viewed as an unfortunate, defensible judgment call, but as a systemic breakdown in basic communication and diagnostic follow-through.

Locked-In Syndrome Is Not a Freak Occurrence

“Jonathan’s story is not an isolated tragedy. Research now shows that minor strokes are missed thirty to fifty percent of the time. Mild and non-specific symptoms such as dizziness, headache, vertigo, or confusion can be misread as something benign. Johns Hopkins researchers estimate that diagnostic errors of all kinds affect twelve million Americans each year. One third of those people are harmed.”

A 30-to-50 percent miss rate for minor stroke is a figure worth pausing on clinically, because it isn’t describing a rare diagnostic trap. The Johns Hopkins estimate of twelve million diagnostic errors annually, with roughly a third resulting in harm, reflects a systemic issue in emergency and primary care diagnostics generally, not a defect specific to any one hospital or physician.

“To help people recognize stroke sooner, advocates use the phrase ‘BE FAST.’ B is for balance. Sudden dizziness or trouble walking. E is for eyes. Blurred or double vision. F is for face. Drooping or uneven smile. A is for arms. Weakness, numbness, or inability to raise one arm. S is for speech. Slurred words or confusion. T is time. Call 911 immediately when these signs appear.”

The addition of “Balance” and “Eyes” to the original FAST acronym reflects a real clinical gap: FAST was designed around anterior-circulation strokes, which produce the classic facial droop and arm weakness. It doesn’t reliably capture posterior-circulation and brainstem strokes, which present differently and are disproportionately represented in missed-stroke cases and subsequent litigation.

Why Medical Providers Often Miss Brainstem Strokes

“Recall again the acronym FAST: Face drooping, Arm weakness, Speech difficulty, Time to call 911. This is effective for most strokes, but brainstem strokes can look different. Symptoms may include sudden dizziness, double vision, nausea, trouble swallowing, or loss of balance. These can appear vague or mimic less serious conditions such as vertigo or migraine.

Emergency physicians see many patients with dizziness and headache. Most don’t have strokes. That is why brainstem strokes are sometimes dismissed. But for the patients who do, the consequences are catastrophic.”

Legally, this is frequently where expert witnesses focus in these cases: not on whether the treating physician failed to diagnose a stroke, but on whether the physician failed to order the imaging or consultation that the presenting symptoms should have triggered under the applicable standard of care.

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Stories of Missed Opportunities

“Consider the story of a man in his fifties who arrived at a small town hospital complaining of dizziness and double vision. A CT scan was read as normal. Doctors diagnosed vertigo and sent him home. Hours later he collapsed. By the time he was transferred to a larger metropolitan hospital, the clot had done irreversible damage. He was left with Locked-In Syndrome.”

This case illustrates a specific and recurring medical pitfall: a “normal” CT scan is not the same as a normal brain. CT imaging is notoriously poor at detecting early ischemic changes in the posterior circulation and brainstem, and a negative CT in a patient with red-flag symptoms generally warrants further imaging, not discharge. From a legal standpoint, over-reliance on a single negative CT result, in the face of symptoms inconsistent with routine vertigo, is a common basis for expert testimony that the standard of care required additional workup before discharge.

“Or the woman in her seventies who was kept waiting for hours in an overcrowded emergency department. By the time she was taken for imaging, the window for tPA had closed. She survived, but with severe and permanent paralysis.”

This case reflects a different category of failure—not a misread scan, but a systems-level delay. In litigation, cases involving ED overcrowding or triage delays often raise questions not just about individual physician judgment but about whether hospital staffing, triage protocols, or resource allocation contributed to the harm, which can broaden the scope of a claim beyond the treating physician to the institution itself.

When the Questions Won’t Go Away

“For some families, questions linger even after gathering records and reconstructing timelines. When those questions remain unanswered, it may be time to consider a legal review. This does not mean filing a lawsuit immediately. It means asking an attorney experienced in medical cases to examine the facts and provide an objective opinion.

A legal review typically begins with a consultation. The attorney will listen to your account, review the medical records, and, if warranted, consult independent physicians who can evaluate whether the standard of care was followed. They’ll look at the timeline: when symptoms began, when imaging was performed, when treatment was provided, and whether opportunities were missed. They may also assess whether hospital systems or staffing contributed to delays.”

This is the standard structure of a pre-suit medical malpractice evaluation: establishing the timeline, retaining an independent medical expert to assess whether the applicable standard of care was breached, and determining whether that breach was a proximate cause of the injury. All three elements—duty, breach, and causation—generally have to be supported by expert opinion before a case has legal merit, which is why an early record review matters more than initial impressions of what “feels” like an error.

In some cases, an error is found. In others, it is determined that medical providers did all they could to prevent this unfortunate outcome. In both cases, families gain information and perspective they didn’t have before. Families can choose to take this information and move on, or they can work with our team to fight for justice and the compensation their loved one needs for their care.

Why We Wrote This Book

Memoirs written by people living with locked-in syndrome already exist, and they matter. But we kept noticing what wasn’t out there: a resource written specifically for the families and caregivers standing on the other side of that diagnosis, with far more questions than answers. Jonathan’s story, the brainstem stroke research behind it, and other cases involving locked-in syndrome are covered in full in our new book. If your loved one was just diagnosed and you find your mind swimming, this book was written to help you keep your head above water.

If you have any further questions, a locked-in syndrome lawyer from Newsome Law is here to help.

Read more about Rich Newsome

Rich Newsome

Catastrophic Injury Locked-In Syndrome Attorney

Rich Newsome is a dedicated attorney specializing in catastrophic injury and medical malpractice cases. With over 25 years of experience, she is committed to advocating for victims and their families, ensuring they receive the justice and compensation they deserve.