Hope Johnson, 20, was a student who was considering hormonal birth control. In doing so, she underwent a blood test to determine whether she was at risk for blood clots. Although the test for Factor V Leiden was positive for a clotting mutation, Johnson’s treating ob/gyn told her that her Factor V Leiden results were normal.
About one month later, after starting birth control pills, she went to Auburn Urgent Care complaining of shortness of breath, chest pain, cough, headache and sore throat. She told the staff there that she was taking birth control pills. Dr. Zenon Bednarski, the owner and supervising physician of the clinic, diagnosed Ms. Johnson with pneumonia and bronchitis after an X-ray was taken. The doctor prescribed an antibiotic and sent Johnson home to return only if her condition worsened.
Ms. Johnson returned to the clinic two days later when her chest pain and shortness of breath became much worse. She reported these symptoms to newly hired Dr. David Willis who ordered a CBC (complete blood count), which showed an oxygen saturation level of 91. Dr. Willis performed no physical exam. He was unable to access Johnson’s medical chart from the previous clinic visit, diagnosed a high white blood count and shortness of breath and prescribed an inhaler. The very next day, Hope Johnson died of massive pulmonary emboli. She was survived by her parents and two siblings.