Colombini-Leaks | How Did a 6-Year-Old Boy Die in MRI Accident?

First, let me say that this isn’t a ‘leak’ in the sense that none of the information I’m about to share is (any longer) confidential. This information is all public record as a result of court filings for the now-settled civil suit surrounding the 2001 MRI fatality of Michael Colombini. There are documents associated with that civil lawsuit which did not wind up as filings with the court and therefore are not a part of the public record. I have no difficulty not releasing those because (among other reasons) I don’t have any of them.

“Why — now — ten years later would you post these documents?”

Excellent question! Here’s why I didn’t publish these long ago…

I didn’t have them.

Yes, the civil suit had been underway for years. Yes, individual documents had been filed and made public during the course of the civil litigation, but the civil suit was only resolved a year ago and it took several months for the last of the documents to be made public through the Westchester County Clerk’s Office (who, by the way, were profoundly helpful in accessing these public records).

Here’s why I am publishing them now… Despite the fact that this is the watershed event in MR safety, the degree to which the industry has really dissected this event and identified the causative factors has been wanting. Desperately wanting.

I’m currently working with a colleague on a root-cause-analysis of this event, drilling down through the simple (don’t have ferrous oxygen tanks in the MR suite) to get at more meaningful elements of this accident that we can work to prevent similar accidents. It promises to be unlike anything you’ve learned about why this accident happened.

Given the trajectory of MR accidents and adverse events, this sort of analysis appears to be desperately needed.

Multi-Year FDA Data on MRI Accidents

So, what are the documents? They are transcripts of the depositions of many of the key people involved in the accident and couple of ‘official’ reviews. These are the source materials. The news accounts you’ve previously read are all synthesized from these (or from others’  interpretations of these). If you’re so inclined, you can download and read these for yourself.

The essential elements of the sequence of events for the accident are these:

  • Michael Colombini, a young boy, was injured from a playground accident
  • The ER had a head CT run, which revealed an unknown / asymptomatic brain tumor
  • The boy had surgery very shortly thereafter to remove the tumor
  • Prior to discharge, the boy was sent for a baseline MRI as a reference for future monitoring
  • The boy was sedated prior to the exam and placed in the MR with a cannula to deliver oxygen
  • Before the exam began, the anesthesiologist observed a decline in O2 saturation, and realized that the oxygen from the wall outlet was not flowing, despite his attempts to turn it up
  • The anesthesiologist called the technologist who was to administer the exam to the door of the MR room, instructing her to find and fix the source of the problem with the oxygen flow
  • This technologist was not familiar with the oxygen supply system, which — in apparent violation of codes — was fed to only the MR exam room from a bulk cylinder without any pressure or flow alarms
  • The technologist sought her colleague who she believed knew the oxygen system and together they entered the MR equipment room to try and fix the supply problem
  • The anesthesiologist cried out for help, though the technologists in the MR equipment room could not hear this
  • A nurse (who had accompanied an earlier patient to the MR suite was returning to retrieve an item she had left) heard the anesthesiologist’s cries for help and handed him a portable cylinder near the door to the MR exam room
  • The anesthesiologist turned to approach the boy with the oxygen tank when the magnetic attractive force of the MRI pulled the cylinder from the doctor’s grasp
  • The tank flew into the MRI where it struck the boy in the face and head, inflicting fatal wounds

The following PDF documents vary in size from 1 MB to 25 MB, and will take a few minutes to download, depending on your connection speed.

Deposition of Patricia Lauria, technologist who was to have administered the Colombini scan
Deposition of Paul Daniels
, other technologist on duty who assisted in the repair of the oxygen supply
Deposition of Jian Hou, MD
, anesthesiologist who sedated / monitored Colombini for the MR exam
Deposition of Terrence Matalon, MD
, Radiologist who was simultaneously the hospital’s Director of Radiology and president of the private company subcontracted by the hospital to provide operations for the MRI service
New York State Department of Health incident report
Westchester Medical Center incident review

As you might suspect, these documents are but the tip of the iceberg of the body of the court filings in this civil suit. However, for those interested in what happened and why (as opposed to the legal maneuvering), these documents are the most illuminating.

In the months ahead, the 10th anniversary of the 2001 Colombini fatality will include a deeper look into this accident and the changes that have taken place (and those that are still needed if we wish to avoid repeating this accident). This has begun, slowly, with the new building code requirements that are being adopted by various US states and the Joint Commission, but may pick up steam with federal government intervention.

Please check back periodically for the latest information on MRI safety… both as it relates to specific preventions, such as ferromagnetic detection systems, and broader awareness such as knowledge of the factors in the Colombini fatality.

Tobias Gilk,
President & MRI Safety Director — Mednovus, Inc.
Sr. Vice President —

Click for Tobias Gilk's Twitter Page Click here for Tobias’ Twitter Profile

9 thoughts on “Colombini-Leaks | How Did a 6-Year-Old Boy Die in MRI Accident?

  1. Pingback: Tweets that mention Colombini-Leaks | How Did a 6-Year-Old Boy Die in MRI Accident? « MRI Metal Detector Blog --

  2. Pingback: When doin’ it wrong is fatal « Whispers of a Barefoot Medical Student

  3. Linda Bigus

    Excellent account of the drastic and life altering day, that started the journey of AWARENESS of MRI Safety. That is just the tip of the iceberg, that changed poor Michael’s life, but, everyone both related to him, as well as the MRI Community! Thank You, Tobias, for reminding all of us, Technologist’s, Doctors, Nurses, that MRI Safety is to be taken very seriously. May Little Michael RIP. His short life has taught all of us so many things! On this week, MRI Safety week, lets honor that young man by caring, sharing, and learning, so someone else never has to go through this again! Thank you again for sharing with us, Tobias!

  4. ew

    Dear Tobias Gilk: I have been curious to know the danger of MRI and Radiology scanning.
    in 1983 i had intestinal surgery and again in 1985 for blockage. After this time, I remember feeling a
    wire or small hard object along the stitches between my breast. I was never told what type of fiber it was
    but since that time I have been given several MRI’s for back (1986) and in 2000 – 2016 for knee, neck and shoulder injuries. How can I find out what kind of object was used in early 1983 & 1985 that may have damaged my stomach and intestines and what harm could be done since I have unusually bloating and gas, and after last MRI of 2016 for neck and shoulder, I feel like my stomach is painted with heavy metal.
    I have complained of these problems and given medications, but I can no longer feel the wire or object.ew

  5. Tobias Gilk Post author


    Your questions seem to be asking for a medical diagnosis, which shouldn’t be given by anybody without an appropriate examination. If you have concerns for your health, I would urge you to bring this to the attention of your physician.



  6. Winnie

    Thanks so much for this informative website.

    I am the anaesthesiologist currently tasked with setting up a safe sedation for MRI service at my hospital in Nairobi. This article in your blog is of immense importance to anaesthesiologists. The MRI room is considered particularly hazardous in our practise. We are unfamiliar with the environment, our regular monitoring tools and equipment arent MRI compatible and we are obligated to make do with unfamiliar tools. Sedation is also not a skill most of us employ in our regular OR practise- we tend to use anaesthetic doses more often.

    I WISH your blog had more on safe sedation in the MRI unit as quite a number of high risk patients require this for their MRI procedures.

    Thanks again!

  7. Tobias Gilk Post author


    Thank you for your comment. Anesthesia is one of the most difficult areas of MRI safety, and I’m very pleased that the American Society of Anesthesiologists has a very good practice advisory on this very topic.

    In my experience, the implementation of MRI safety between radiology and anesthesiology personnel needs a great deal of individualization to the structure and operational needs of each site. Yes, the principles of safe operation are pretty universal, but the implementation usually needs some pretty significant customization.

    Does your hospital have a designated MR Safety Officer?


  8. Winnie

    Hello again!

    No, we don’t ?. A lot is taken for granted… & that’s why I feel particularly saddened by this anaesthesiologist’s experience.
    Thanks for the link. I hope I find what I’m looking for there.

Leave a Reply

Your email address will not be published. Required fields are marked *

Change the CAPTCHA codeSpeak the CAPTCHA code