The Federal Court Division of Vaccine Injury Compensation (DVIC) ruled on November 9, 2007 that a child’s parents would receive compensation due to a vaccine injury. Recently the amount of compensation was named – $1.5 million plus $500,000 a year for treatment. There has been much discussion about what the award means. With a charged issue such as this one, wording is very important. The court’s wording in this case is as follows:
“DVIC has concluded that the facts of this case meet the statutory criteria for demonstrating that the vaccinations CHILD received on July 19, 2000, significantly aggravated an underlying mitochondrial disorder, which predisposed her to deficits in cellular energy metabolism, and manifested as a regressive encephalopathy with features of autism spectrum disorder.”
With a very careful reading of the court’s decision, we can put what the court determined was applicable to the case in a Cause Map, or visual root cause analysis. (I’ve also recorded the chronological information in a timeline, used to assist with our understanding of the issue. The information from the timeline is also from the ruling.)
First we can enter the impacts to the goals in the outline. The patient safety goal was impacted because a child wound up brain-damaged (or with encephalopathy). The resulting payment of over $1.5M is an impact to the financial goals of the vaccine injury board. Based on the ruling, the vaccines aggravated an underlying condition, which can be considered an impact to the patient services and environmental goals. Additionally, in this particular circumstance the child received vaccines not on schedule. This could be considered an impact to the compliance goal.
Beginning with the most important goal – patient safety – we build the Cause Map. The patient’s encephalopathy was determined to have been caused by an underlying condition that was aggravated by the receipt of vaccines against 9 diseases all at once. However, the link between this and the encephalopathy isn’t yet clear. Rather than just stopping our Cause Map, we can add a “?” in the middle of the cause-and-effect relationship, and highlight this unclear relationship. This allows us to focus our attention. Even with this question mark in the middle of the map, we can still do a lot to clarify the cause-and-effect causes.
For example, based on the child’s physicians’ diagnoses, we know that the underlying condition was a mitochondrial disorder. We also know that the child received vaccines against 9 diseases at once because she was behind on vaccines, having skipped some doses while she was ill.
Even with the uncertainty surrounding this analysis, the Cause Map can still provide clarity to the issue. It can also help lead to possible solutions (though adding more detail will allow for even more). For example, doctors may adjust catch-up vaccination schedules based on this incident, resulting in fewer vaccines being given at once.