Podcast: MRI tragedy, key aspects of the Colombini family's lawsuit

Warning: This episode of "The Invisible Force" podcast contains disturbing and graphic details about the fatal MRI accident that triggered a national reckoning over MRI safety -- and the policies that followed in the U.S.

The AuntMinnie Podcast Network continues with the second of a three-part Invisible Force case study on the death of 6-year-old Michael Colombini. Colombini died from actions of healthcare personnel during a post-op MRI scan at Westchester Medical Center in Valhalla, NY, in 2001.

Beyond the graphic details of the accident itself -- a metal oxygen tank pulled in, out, and back into the scanner -- MRI experts Tobias "Toby" Gilk and John Posh walk through the frantic effort by the code team, paramedics, anesthesiologist, and nurse to free the injured boy trapped inside the shattered head coil and MRI scanner bore.

How were the MRI technologists engaged during the emergency? According to Gilk, they were in the equipment room trying to fix the oxygen supply deficiency -- the failure that triggered a fatal error of personnel onsite. The technologists had no idea what was unfolding during the several minutes they spent in that room, he recalls.

Although Colombini initially responded to treatment following the accident, he died within two days from fatal head trauma after being struck by the oxygen tank at the time of a baseline MRI scan following brain surgery, according to Posh.

"The shockwaves immediately reverberated through the radiology community," Gilk said. 

Hospital president and CEO Edward Stolzenberg at the time publicly acknowledged a "systemic issue with the hospital" -- a candid admission that, in hindsight, amounted to a colossal failure in crisis communication, according to Gilk. Likewise, statements from other staff were noble, brave, and honest, but from a legal perspective, also completely wrong, he added.

Unlike Nassau Open MRI, Westchester Medical Center was a state-licensed facility. Therefore, the New York State Department of Health investigated the July 27, 2001 accident.

Without any minimum MRI patient safety requirements on the books, on what basis could regulators even issue citations? In the end, the state could only fine the hospital under existing code for the medical gas system -- a $22,000 penalty amounting to roughly two or three days of MRI service revenue in 2001, Posh noted.

The Colombini case stands as the single most important reference point in the history of MRI safety in the U.S. In its wake, the American College of Radiology (ACR) moved quickly to convene a blue-ribbon panel on MRI safety, which went on to produce the ACR's first white paper on the subject -- a document that would go on to shape safety protocols across the industry.

Not surprisingly, the Colombini family pursued a civil lawsuit in 2002, naming a wide range of defendants: the hospital itself, the scanner manufacturer, the MRI technologists on duty, the anesthesiologist, the nurse who handed over the oxygen tank, and the hospital's director of radiology -- who also happened to own and operate the MRI center. 

The second half of the episode is devoted to key aspects of the family's $20 million lawsuit that shed light on hospital policies and duties of MRI personnel, especially MRI technologists. The litigation dragged on for six years, whittling away at most of the defendants named, but was ultimately settled before ever reaching trial.

"MRI injury cases are almost the reverse of other types of medical malpractice cases -- the injury alone is almost always potent proof of negligence," Posh said.

Listen to the full discussion of both the Colombini accident and the family's lawsuit now. Stay tuned for Episode 3 which is scheduled to commemorate MRI Safety Week (July 26-August 1, 2026) and the 25th anniversary of the event.