In the absence of well-defined staffing guidelines, the courts have had no reliable standard for ruling on cases of alleged understaffing. Each case has been decided on an individual basis.

The decision in the landmark case Darling v. Charleston Community Memorial Hospital (1965) was based partly on the issue of understaffing. A young man broke his leg while playing football and was taken to Charleston’s emergency department where the on-call doctor set and cast his leg. The patient began to complain of pain almost immediately. Later, his toes grew swollen and dark, then cold and insensitive, and a stench pervaded his room. Nurses, who checked the leg only a few times per day, failed to report its worsening condition. When the cast was removed 3 days later, the necrotic condition of the leg was apparent. After making several surgical attempts to save the leg, the surgeon had to amputate below the knee.

After an out-of-court settlement with the doctor who applied the cast, the court found the hospital liable for failing to have enough specially trained nurses available at all times to recognize the patient’s serious condition and alert the medical staff.

Since the Darling case, several similar cases have been tried — for example, Cline v. Lun (1973), Sanchez v. Bay General Hospital (1981), and Harrell v. Louis Smith Memorial Hospital (1990). Almost every case involved a nurse who failed to continuously monitor her patient’s condition — especially his vital signs — and to report significant changes to the attending doctor. In each case the courts have emphasized the: