It’s just a virus, the ER told him. Days later, he was dead.

Sam updated his parents by text as he was leaving the hospital on Monday night. “Just a bad virus, will have to advil, vomit, and hydrate it out,” he wrote.

“Ugh,” his father responded, “Good news re no major known problem (I guess).”

On Thursday, Sept. 21, Sam’s father, Villiers Terblanche, received a call from a Columbia dean. “When he said ‘I’ve got sad news,’ I knew something bad happened,” Terblanche recalled in a deposition. He had the call on speaker phone in the family’s living room. “It became really chaotic for a few minutes because Louise” — Sam’s mother — “was screaming with the most piercing primal scream I’ve heard in my life and Ben” — Sam’s younger brother — “lost it.”

Two years after Sam’s death, his father (who is known as “VT”), still can’t understand how his 20-year-old son could have sought help at the Mount Sinai Morningside emergency department twice in 24 hours then died alone in his dorm room two days later.

Terblanche met with the chief medical officer, Tracy Breen (who has since become the hospital’s president), two months after Sam died. He made a recording of the meeting and handed it over as part of pretrial discovery. In a well-lit room, seated at a conference table, Breen explained that after an internal review, Mount Sinai Morningside had concluded that it was “comfortable, satisfied, whatever totally non-helpful word we use” with its decision to discharge Sam from the ER. It was a “gut punch,” Terblanche told me.

Breen conceded that Sam’s death was an emergency provider’s “worst nightmare” and would likely prompt staff to “wonder and feel, like ‘Did I get it wrong?’” At the same time, she informed Terblanche that the details of the review were off limits to him — “confidential and internal.”

Terblanche has been a lawyer his whole professional life, and he sees that meeting as a turning point. How can an executive acknowledge that the best doctors sometimes err while also insisting, without providing evidence, that the hospital was blameless? From that moment, he realized that if he wanted answers, he would have to fight. In August 2024, he sued Mount Sinai Morningside and five doctors who work there for medical malpractice and wrongful death. In a statement, Mount Sinai expressed sympathy for the Terblanche family but declined to comment on Sam’s case.

“Any patient loss profoundly affects not only families, but also the care teams who dedicate themselves to providing the highest quality care,” the statement said.

‘Moving the Meat’

Legal proceedings in Terblanche v. Mount Sinai Morningside will linger on the narrow legal definition of “standard of care.” But the case of Sam Terblanche underscores looming questions for everyone who uses emergency rooms: Can we expect emergency physicians, imperfect people treating idiosyncratic patients, to perform almost flawlessly in a system that is stretched to the limit? And when care is flawed, where is the line between adequate and failing — and who, beyond judges and juries, makes that call? There were 155 million visits to emergency rooms in 2022, up from 130 million in 2018, and that number is expected to increase as President Donald Trump’s Medicaid cuts take effect. A third of Americans have no primary care physician, up from a quarter 10 years ago.

Once last-resort care for midnight fevers, weekend sports injuries and car-wreck victims, the emergency room has become the doctor’s office for millions of people. Patients come in with stomach pain, chest pain and cough; head injuries, overdoses and nonspecific complaints; depression, hypertension and hunger.

“The spectrum of disease is just unbelievable,” said Reuben Strayer, an emergency physician at Maimonides Health in Brooklyn, New York, whose lecture, “Emergency Thinking,” has been viewed nearly 80,000 times on YouTube.

The first job of any emergency physician, as he explained it to me, is to identify and treat patients in need of resuscitation. These assessments are frequently uncomplicated. “If someone just got shot in the chest and they’re unconscious, you know right where they are,” he said.

Far more difficult to determine is which patients are in imminent danger. This requires a rigorous, focused and nuanced assessment of every patient who is neither obviously dying nor obviously well. “You can take vital signs and if their vitals are reassuring and they look OK, the vast majority of them are OK. But not all of them,” Strayer told me. The patient who looks well but is in danger is both a physician’s urgent concern and a needle in a haystack — and “the more ‘well’ patients who use the ED as their primary care, the harder it becomes to find these needles,” he said.

ER staff are under mounting pressure to discharge patients as fast as they can: Cynics among them call their job “moving the meat.” Hospitals are nearing capacity because of aging facilities and economic pressures. In a 2022 letter to President Joe Biden, the American College of Emergency Physicians called “boarding” — in which patients wait in the ER for days and sometimes weeks for hospital admission — “a public health emergency.” While they wait, these very ill patients line the halls of the ER, draining the staff’s time while new patients are always coming in the door.

“You can imagine, when someone comes in with more subtle or not-so-subtle symptoms, there’s a higher risk that they could get missed,” said Allen Kachalia, senior vice president of patient safety and quality at Johns Hopkins Medicine.

As hard as the job is, diagnostic accuracy in the ER is high overall. But a recent systematic review of published research estimated that 5.7% of ER patients will have at least one diagnostic error and 2% have a setback as a result. A fraction, 0.3%, suffer serious harms — including 50 deaths a year in an average ER with 25,000 annual visits. ER doctors have argued with these data, but the problem of misdiagnosis is well established. A common factor in diagnostic errors, the authors wrote, was what they called “the cognitive challenge” of identifying dangerous conditions in patients with nonspecific, mild or transient symptoms.

On his second visit Sam said he still had a headache. “Not the worst headache of his life,” the health record said.

Two ER Visits

VT and Louise Terblanche are South African by birth. Their sons were born in New York City and raised mostly in Abu Dhabi, United Arab Emirates, where VT was a partner at Latham & Watkins. The Terblanches are wealthy but the adjective VT uses most frequently to describe himself is “Calvinist.” He is a sensible, successful man predisposed to trust that authorities have earned their place. In all my conversations with him, over nearly a year, he rarely used the word “grief.”

He told me he still dreams of Sam several times a week, “but I no longer wake up asking myself, ‘Did this really happen or not?’ I know it happened.”

After Sam’s death, the Terblanches moved to New York; VT took a leave from the law firm and enrolled in a master’s program in health policy at New York University. In his effort to understand hospital safety and risk, he learned these oft-cited projections: more than 200,000 people will die each year from preventable medical errors. He was shocked. Conservatively, these estimates amount to at least one fatal Boeing 747 crash per week, Terblanche calculated.

On Sunday, the day after the Yankee Stadium soccer match, Sam started to feel really terrible. In the evening, he walked the one block to the Mount Sinai Morningside ER with a friend. There, he described his headache and chills. With their physical exam, the doctors ruled out meningitis and tested him for flu, COVID and respiratory syncytial virus, known as RSV. (All came back negative.) Sam was given Tylenol and Zofran and sent home.

The next day he felt worse, “really bad lol,” as he wrote in a text message to his girlfriend, Kayla Francais. He had been throwing up all day. He woke from a nap with uncontrollable shivering and suffered painful leg cramps in the shower.

Francais, who was 20 and had been conferring with her mother, said she thought he should go to the ER again.

“I think so too,” replied Sam.

Sam returned to Mount Sinai Morningside just after 8 p.m. on Sept. 18, Monday. In ER parlance, he was a “bounce back,” a patient returning within a short time, always a red flag.

In addition to Sam’s previous complaints, he was now getting winded while walking. He had a cough. According to his medical record, he had a fever of 100.6 and his heart rate was 126 beats per minute. A normal adult heart rate is 60 to 100.

When Aditya Banerjee, then a first-year resident, examined Sam, he had been working in the ER less than a month. “At the time,” he said in his testimony, “I deferred all of my assessments and medical decision-making to the attending physician.” That night it was Samuel Agyare, a veteran physician who said in a deposition that he was working full time at Mount Sinai Morningside and part-time at Lincoln Hospital in the Bronx.

After COVID, Mount Sinai Morningside was struggling. Throughout 2023, nursing staff levels in the ER were so low that in February 2024, an arbitration panel awarded union nurses nearly $1 million for working understaffed shifts. In the three years beginning in 2022, Mount Sinai Morningside received a “C” in safety from the Leapfrog Group, a nonprofit watchdog organization.

On the night of Sam’s second visit, the ER was “very busy,” Agyare testified. As he passed through the waiting room, he recognized Sam, whom he had treated the previous night. Agyare escorted Sam to a bed in the pediatric ER, he said in a deposition, and examined him.

Banerjee testified that he examined Sam, too, then consulted with Agyare and they made a plan. It was Banerjee’s task to document Sam’s care, and as he began to do so, a pop-up appeared on his computer screen. Sam’s fever and heart rate had triggered an automated warning for sepsis, a potentially life-threatening condition in which the immune system has a dangerous reaction to an infection. It requires speedy intervention. To help the hospital comply with state-mandated sepsis regulations, the pop-up provides a checklist of tests and orders used to identify and treat sepsis.

Agyare had instructed Banerjee to hydrate Sam right away but to wait for the results of Sam’s lab work before ordering a chest X-ray or the strong antibiotics used to treat sepsis.

But Banerjee, a novice, got stuck. He couldn’t figure out how to navigate the template to make some but not all of the auto-populated orders. “This was my first patient that triggered the sepsis pathway,” he explained, in testimony. So he asked Connor Welsh, a third-year resident, for help.

At 8:50 p.m., Welsh showed Banerjee how. From his own computer, he clicked into a field on Sam’s chart to assert that sepsis was not likely: “Based on my evaluation,” the automated note said, “this patient does not meet clinical criteria for bacterial sepsis.” And then Welsh recorded what Banerjee said Agyare had said earlier: “Likely viral syndrome. Workup pending.” Welsh’s name appears on the note, but in his deposition he said he never interacted with Sam. Senior residents often help junior ones in this way, he said. “I signed this note based on the discussion with the provider, Dr. Banerjee, based on his evaluation and the medical management of Mr. Terblanche,” he testified.

Meanwhile, Sam was propped up in bed 36, looking worn out. His friend Charlie Sagner was in the waiting room, doing homework. In an update to friends, Sagner would write that Sam looked “Zombie-like.” Around 9 p.m., Sam texted his parents in Abu Dhabi. “Back at ER,” he wrote. “Theyre giving me fluids and doing blood tests”

“Oh honey,” his mother, Louise, replied. “Can I call”

‘Note Bloat’

Sam’s chart is 51 pages long, a catalog of billing codes and abbreviations, check-boxes and shorthand, updates and addenda. The record of the second visit contains numerous contradictions: Sam’s heart rate was documented at 126, yet Banerjee clicked the box “normal.” In one place it says Sam didn’t have a cough, while in another it says he did. The signatures of doctors who testified they never saw Sam — including one who was not in the hospital that night — accompany notes. Vital signs were ordered and not taken, as was an EKG.

Villiers Terblanche has read the record countless times, each time searching for clues. He finds the chart risible: Why would a physician decide to override an alert designed to protect Sam from danger?

Doctors talk about electronic medical records as an unpleasant and frustrating chore. They object to how the charts have evolved to prioritize billing and liability defense over clinical care. And they regard the symphony of well-meaning alerts and pop-ups as a distraction at best.

“Note bloat” refers to the volume of redundant and superfluous messages generated by an electronic medical chart. Automated prompts that assist in medical decision-making are still relatively unsophisticated, Kachalia, the patient safety executive at Johns Hopkins, explained in a phone call. “While they can help, the problem is they often over alert,” like a car that beeps when there’s an obstacle in the way and also when there isn’t, he said. These unreliable warnings can lead to “alert fatigue” and, sometimes, a mental habit of discounting them.

The emergency physicians I spoke to were largely sympathetic to the decision to override the sepsis alert. They reminded me that in 2023, late in the COVID era, ER waiting rooms were full of young patients with viral infections exhibiting fever, headache and nausea. The overwhelming majority would get better.

But they agreed, too, that the record of Sam’s care during his second visit is thin. The check boxes and templates can aid efficiency, several doctors told me, but they also may distract physicians from the patients right in front of them.

Even Breen, the Mount Sinai Morningside executive, conceded during her meeting with Terblanche that decision making was not “well captured in the medical record in general.” After Sam’s death, she told him, “one of the things we talked about with that team is maybe how to better capture that, just to tell your story better.”

Largely absent from Sam’s chart is the “why.” Sam was feeling worse. Why did Agyare assert from the outset that Sam was “unlikely to require admission,” as the health record said? Sam ran short of breath from walking, told at least one doctor that he had a cough, and he couldn’t keep food or drink down. What rationale did Agyare have not to order the antibiotics as a precaution? He explained his thinking in his deposition. Other than a little fever and a high heart rate, Sam’s physical exam “was entirely unremarkable,” he said.

And Agyare said he didn’t order a chest X-ray because Sam’s lungs sounded fine. “The patient was not in respiratory distress. His breath rate was within normal limits,” he said.

Each of the six ER physicians I spoke to noted the omission of the chest X-ray. A doctor seeking to rule out sepsis on a bounce-back patient wants to demonstrate a concerted search for an infection. A chest X-ray might have revealed (or ruled out) pneumonia, bleeding or fluid in the lungs.

But, they warned, it might not have. “It might have been normal and he still might have died,” said Maria Raven, chief of emergency medicine at the University of California, San Francisco Medical Center. Each doctor also emphasized that they weren’t there. They didn’t examine Sam.

Abnormal, but Not Concerning?

In May, I sat with the family and Francais at the Terblanches’ long farmhouse table. We were talking about Sam, who loved a political argument, could be annoying in his certainty and tried to be good, even valiant, in his relationships. He was the kind of boyfriend who helped Francais make bracelets before a Taylor Swift concert — and then wore one himself that said “boyfriend.” Sam was an environmentalist and a longtime supporter of Palestinian rights. An empath, he ribbed his father for his steadfast pose of invulnerability. But in general he was, as Francais put it, referencing Taylor Swift, “a pathological people pleaser.”

Francais has a theory of the case. Bias against women and people of color in emergency departments has long been documented, Francais pointed out. She was a gender-studies major at Barnard. Sam may not have raised alarm among the emergency staff because he was a young man who didn’t want to “seem weak.” She believes Sam knew how sick he was: “He just didn’t know how to advocate for himself. He didn’t know how to speak up.”

Sam was young. He was healthy and fit. This in itself can be an obstacle to diagnosis. The ER doctors I spoke to described how the bodies of young people often compensate for illness or trauma until they can’t anymore. They look well, or well enough, and then “they fall off a cliff,” as several doctors put it to me.

When asked to recall Sam’s appearance during a deposition in August, Agyare remembered “a well young man who communicated well and was not in distress.”

Sam’s lab results started coming in after 9 p.m. Of the more than 70 results listed in his chart, nearly three dozen are flagged with little arrows and exclamation points as “abnormal.” But in deposition testimony, Agyare said that in Sam’s case these flags were not clinically concerning. The emergency doctors I spoke with largely agreed; “no smoking gun,” one of them said.

There is no single blood test for sepsis. Sam’s white blood cell count was normal, and in sepsis it is often high (or in the case of overwhelming sepsis, very low). His lactate, another marker for sepsis, was also normal.

There’s a saying in medicine: “When you hear hoofbeats, think of horses, not zebras.” A patient’s symptoms usually support the most plausible diagnosis, not the rare possibility. Villiers Terblanche believes his son died of sepsis, a leading cause of death in hospitals and notoriously hard to diagnose.

Benjamin Miko, an assistant professor of infectious diseases at Columbia University, is prepared to testify as an expert witness in Sam’s case. The electronic health record warned of sepsis in two different ways, he told me, “so it’s not really up to the doctors to say, ‘We don’t want to do an X-ray. We don’t want to do antibiotics.’”

But Sam’s autopsy report is inconclusive on the role of sepsis. According to the New York City Office of Chief Medical Examiner, the primary cause of Sam’s death was “pulmonary hemorrhage of unknown etiology”: he bled massively from his lungs, but the examiner could not say why. A blood culture taken on Sam’s second ER visit did not grow out, meaning if Sam had a dangerous infection it was not yet detectable in his blood. Sam’s heart, post mortem, was enlarged, as was his liver. His spleen was congested. His kidney showed tissue damage. (Sam’s toxicology screen was negative.)

David Strayer, an expert autopsy pathologist who coedited the medical textbook “Rubin’s Pathology,” reviewed the medical documents in this case. (He is the father of Reuben Strayer, the ER doctor and blogger.) David Strayer didn’t see the pathology slides, but believes that sepsis is an unlikely culprit in Sam’s death. He thinks Sam was a zebra, the rare patient with an outlier diagnosis: an autoimmune disease, a clotting disorder or an outsized reaction to something he ingested or drank. An additional autopsy by the Cleveland Clinic suggested the possibility of multisystem inflammatory syndrome associated with COVID. Sam had COVID several weeks earlier, though at the hospital he tested negative.

Overall, Sam’s lab values were off. His platelets, red blood cells and hemoglobin were low. (“He’s a 20-year-old guy. His red blood counts should not be low. He doesn’t have a monthly period. He doesn’t have a gaping wound,” Strayer said.) His sodium was low. His glucose was high. His creatinine, which measures kidney function, was “within normal limits,” but high for a person his age. His urinalysis showed the presence of blood and elevated white cells.

Sam’s lab results “do indicate that something serious is going on there. And it’s not at all clear what it is,” Strayer said.

But how do emergency doctors act on this level of complexity in their high-volume, fast turnover environments? Should they be expected to follow mysterious blood results over days? Or phone patients after discharge to check up on them? The realities of hospital crowding make doctors reluctant to insist on hospital admission when the particulars don’t obviously seem to merit it.

An ER doctor can insist that a patient follow up with a primary care doctor, said Raven, of UCSF. Sometimes she will keep a patient for observation, or to recheck values that may be concerning, she added. At Mount Sinai Morningside, doctors in the pediatric ER, where Sam was treated, don’t have that capacity, Agyare said in his deposition: “You have to make a decision on them. Either coming into the hospital or being discharged.”

Raven paused for a moment during our talk. “I think about this a lot. Like, our job is kind of perilous,” she said. “I think we all try to put it out of our minds when we go into a shift every day, but bad things can happen. And it’s on you to be extremely vigilant. And to some extent lucky, honestly.”

Delirium Sets In

Around 10:30 p.m., after the hospital shift change, Neil Makhijani, another resident, took over from Banerjee and stopped by bed 36 to check on Sam. By then, Charlie Sagner had finished his homework and was sitting next to him, chatting. “Patient reassessed. Reports feeling better,” Makhijani’s note said. He spoke to Sam about his lab results. Sam felt reassured: “Tested normal on all blood stuff,” he wrote to his parents.

Sam told Makhijani that he was ready to go home. “I think he was, just kind of like, ‘Get me out of here,’” Sagner told me. “There weren’t any obvious signs that he still, like, wasn’t right.” The doctor ordered a second liter of IV fluids and started the discharge work. In the “diagnosis” field, he repeated the earlier conclusion, “acute viral syndrome.”

The discharge document said, “If you develop any new or worsening symptoms, or the symptoms you still have persist for longer than we discussed, you should return to the Emergency Department immediately.” It noted that Sam should follow up with a primary care physician. Sam’s heart rate was still abnormally high, but he was able to keep food and drink down. Makhijani gave him an excuse note saying he would be ready to return to school by Wednesday. He also gave Sam a copy of his lab results, which Sam stacked in a neat pile on his desk.

Courtney Mangus, an emergency physician at the University of Michigan, emphasized how important it is for doctors to level with patients when they’re not sure of a diagnosis. Such honesty can help patients overcome feeling “sheepish” about going back a third time, she said, speaking in general terms.

“I cant believe i still just have a virus,” Sam wrote to his friends as he left the hospital. “How anticlimatic. I really thought i was dying”

Later that night, he wrote to Francais: “First thing im havign when i can eat again is chick fil a”

This is the part that haunts Sam’s family and closest friends. Sam went to the ER because he felt sick. Then he went back, sicker. The doctors told him he had a virus. He — and everyone he knew — believed them. “I went with Sam to the hospital and they said it was fine,” Sagner told me. “So I didn’t have much reason to doubt what was going on because I trusted the hospital to do its job.” In his last days, Sam was quarantining. He didn’t want his friends to catch what he had.

On Tuesday, Sam woke up feeling somewhat better. By text, he asked his parents what he should eat.

“plain bagels,” wrote his father.

“Chicken is really good,” suggested his mother.

Delirium set in that afternoon. “I miss human society,” he texted Francais around 7 p.m. “I convincrd myself i was tue head of the vikings,” he wrote. “I need to stop making religions. I convince myself I have a following All under the covers with me.”

“LMAO,” wrote Francais. And then: “hang in there pls.”

On Wednesday, Sam’s parents checked in again. His father wondered, “how is the patient doing,” and reminded Sam to say happy birthday to Ben. By text, Francais started sending Sam cartoon animals with hearts for eyes. His absence was making her anxious, she wrote, and she needed him to be more in touch.

“I will check innmore,” he wrote. “I promise.”

“When is this gonna end?” she asked.

“Will talk when I’m up again,” Sam wrote. “Idek.”

When Sam didn’t respond to her texts Thursday morning, Francais called Sagner, who informed campus security.

The depositions in the case of Terblanche v. Mount Sinai Morningside began in January 2025. VT always attends. He knows it’s naive, but he wishes that someone in the room would drop their defensiveness and take some accountability for what happened to Sam. The Mount Sinai Morningside doctors are well prepped. Their answers are cautious and unembellished.

VT finds some of these sessions so anguishing that he takes the next day off and rides 60 or 70 miles on his bike. He calls these his “antidepressant bike rides.”

For Louise, too, the legal machinations are heartbreaking. Every deposition — relayed by her husband who takes copious notes — brings back memories of the day when she stood in the corner of Sam’s dorm room holding his pillow while his friends ripped his posters off the walls. The picture of Sam’s last week has come into focus bit by bit.

“The fact that we all just think it was preventable is just horrendous,” she told me. “And then also, I mean, I don’t think we’ll ever know what he died of. We don’t know what the infection was. Maybe it was something horrible and maybe he would have died anyway. But the fact that he died alone without help. That, for me, is hard.”

Louise misses her community in Abu Dhabi, and in Croton she has devoted herself to gardening. “I couldn’t stop planting,” she said. “I want the bees to come.” She thinks a thriving bee colony would be a fitting tribute to Sam, her environmentalist son. As depositions continue through autumn 2025, VT will depart Latham & Watkins. He is looking for a new career that honors Sam, perhaps in sepsis awareness and patient safety, perhaps with a side gig teaching law “at some leafy college,” he told me. He is retiring earlier than he intended, but Sam’s death changed him too much for him to stay his course.

In August, Ben Terblanche went off to college. When I spoke to him last spring, he talked about how excited he was “to find out who I am now, to have conversations and think about things other than this.” He was upended by his brother’s death. “I talked to him about everything,” Ben told me. The prospect of a new city with different people gave him a sense of possibility.

And then in September, almost exactly two years after Sam died, Ben got sick. His parents advised him to go to student health services, where he was diagnosed with strep throat and given antibiotics. But “he kept on getting worse,” VT told me, “and so he went back. And they looked at him again and said ‘OK, this is more serious.’”

Student health directed him to the local large urban ER.

In the end, Ben was fine, the ER staff skilled and efficient. They drained an abscess on his tonsil and sent him home. But before his discharge, when his care was ongoing, Ben sent a selfie to his parents: he was lying on a gurney, hooked up to machines and tubes. It was an eerie facsimile of a photo Sam had sent two years before. “We both went into almost a panic,” VT said. “This is irrational and paranoid. I’m just telling you how I felt. Goodness, we cannot — something cannot — happen to the other child.”

This article originally appeared in The New York Times.