COMMENT

Hospital changed nothing
after Lisa’s untimely death

By David Baker
September 7, 2009

The alleged negligence that preceded the death of Alec MacKenzie in Samaritan Hospital is shockingly similar to what, according to medical records, happened to Lisa Baker in the same hospital just seven months earlier.

She, like Mr. MacKenzie, had previously been a patient at Samaritan Hospital and was known to have volatile glucose levels. She, too, had a specific written physician’s order in her chart, instructing nurses to use a printed protocol on treating hypoglycemia. She, too, had a low glucose reading during the evening before she was injured. She, too, had no check of glucose levels done for several hours prior to being found unconscious.

Mr. MacKenzie was “unresponsive” when found but there is no indication in the records that he was not breathing or that his heart had stopped. His glucose level was said to be 38 mg/dL. In Lisa’s case, the damage was so severe that she had no pulse or respiration, and, after CPR was performed, was immediately placed on life support. According to a notation made in a medical record at the time, her glucose reading was 2 mg/dL.

After three days in a medically induced coma the ventilator was removed and she briefly became semiconscious, unable to speak but able to respond to simple questions with hand squeezes. But after only a few hours she was struggling to breathe. She was put back on the ventilator and lapsed into a deep, irreversible coma.

She died two weeks later.

Samaritan Hospital’s management clearly had learned nothing from Lisa’s excruciatingly painful and totally preventable death. Mr. MacKenzie’s case suggests a breathtaking arrogance rather than any desire to acknowledge mistakes and prevent them from happening again. It seems that with an insurance company ready to defend every claim, no matter how obvious the liability, and a local print media that for 10 years has kept virtually every malpractice lawsuit off its pages, the hospital’s management saw no reason to stop the devastating financial and emotional toll of deaths and injuries within its facilities.

That prompts the question: How many more Lisa Bakers and Alec MacKenzies are there hidden in Samaritan Hospital’s records? Cases which for many reasons did not result in a lawsuit and so are not accessible in county clerks’ offices. We know that doctors and hospital managers – and even state regulators – are very unlikely to volunteer information about an error. In fact the opposite is true; as an earlier post on this page shows, the state Health Department refuses to provide details of its investigations of apparent negligence, even to members of the Legislature.

And wouldn’t Samaritan’s management have made big changes to the way a patient with diabetes is monitored if they knew that details of lawsuits like that filed by Mr. MacKenzie’s relatives would probably be published in the newspapers? Instead, it was right at that time that the huge number of Northeast Health advertisements in the Times Union prompted a letter to the editor and the publisher of the paper, asking them to explain the absence of any stories about lawsuits alleging medical malpractice filed against Northeast Health and other advertisers.

There was no response.

What exists here is an unconscionable culture of concealment. It has to end. That is why details of many of these lawsuits will soon be available on a new Web page which – following the discovery of the MacKenzie case – will start with those filed against the area’s largest healthcare provider, Northeast Health Inc.

In addition to Samaritan Hospital, Northeast also operates Albany Memorial Hospital, six adult daycare centers, five assisted living facilities, eight primary care offices and a home care organization.

And even if every lawsuit is revealed it would likely represent only a fraction of cases where there was negligence. Studies have indicated that as few as one in seven errors that cause death or serious injury result in a lawsuit.

The new page is expected to be launched later this year.

***