A horrific death

 

This Web site is dedicated to the memory of Lisa Marie Baker, who at age 10 developed insulin-dependent diabetes.  Lisa died in 2003 at the age of 42 after her blood-glucose level dropped to near zero while she was a patient in Samaritan Hospital in Troy, New York.

This article is one of many from this blog that will appear in a book about the events surrounding Lisa’s tragic death, due to be published later this year.

Hospital’s failure to provide basic care caused 

death of patient with insulin-dependent diabetes

  

By David Baker

Posted on Jan. 7, 2025

  My wife, Lisa, always knew when her blood glucose level was low.  She would tell me, and a finger-stick check would show she was right.

    I would first give her orange juice - which would rapidly bring up the blood/glucose to a safe level. 

   But without something longer-lasting, her sugar level would soon have dropped.  So I also would give her bread or crackers - carbohydrates - which are digested less rapidly but last longer.

   After 15 minutes, I would do another blood glucose test, by which time the level would usually have increased to at least a safe 80 milligrams of glucose per deciliter of blood (80 mg/dL)

   And then I would do further tests every 20 minutes until two consecutive tests showed the level had stabilized in a safe range. 

   All that is basic care for someone with insulin-dependent diabetes who has an episode of hypoglycemia - a low blood glucose level.  It’s spelled out in the hospital’s hypoglycemia protocol.  Any nurse worth her or his license should have known it.

  But it is not what Lisa got in Samaritan Hospital on the night of Nov. 10-11, 2003.

  According to the hospital’s medical chart, at around 9 that evening a test showed a level of 55 mg/dL,  just below what the protocol states is hypoglycemia. Dextrose was given to her via an IV, which would cause a very rapid, but without carbohydrates - an unsustainable increase in her glucose level.

   But according to the chart, she was not given the carbohydrates specified in the hospital’s hypoglycemia protocol, which Dr. Rajinder Jain had ordered earlier that evening to be followed if Lisa became hypoglycemic, an order that nurse Marie Martin noted in the chart.

   At 9 p.m., nurse Martin made the following notation:  “BS [blood sugar] 55. Dextrose  D5 via IV. Pt alert and oriented  X 3. Will retest BS.”

   At 9:30 p.m. nurse Martin made another entry in the chart:  “Juice PO [by mouth] given.“  And then at 10 p.m.: “BS 116, feels better.” -  suggesting Lisa had complained of feeling unwell.  

    But there’s no record in the chart that the hypoglycemia protocol ordered by Dr. Jain and acknowledged in the chart by nurse Martin had been followed after the 7 p.m. reading of 55 mg/dL.

   At midnight, Mary Ann Lee took over Lisa’s care.  According to the chart, nurse Lee’s first check on Lisa was at 2.07 a.m. That was when a heart monitor alarm sounded in the nurses’ station adjacent to Lisa’s room, triggered by a heart rate of 35 beats a minute, far below a normal resting rate of 60 beats a minute. Nurse Lee went to Lisa’s bedside and, as she recorded in the chart, found Lisa “…hard to arouse and very pale and sweaty. BS [blood sugar] checked — 2. No respiration noted. HR [heart rate] remained low 30s. Call a code, atropine given, D50 [dextrose] IV given, CPR started. — [signed] Mary Ann Lee, RN” 

   It was too late.  The low glucose level had caused irreversible damage to Lisa's brain cells.  After a week she become completely unresponsive, never regaining consciousness.

****

   As noted at the beginning of this post, Lisa would have known that her glucose level was dropping, and that without nutrition, she would die.  The shear terror she would have experienced at this point can only be be imagined.  Blind, she may have tried to find and press her call button - it will never be known - but as anyone who has been on a hospital ward knows, these bells ring constantly, tuned out by nurses and others.  Sinking down into a bottomless black hole, she would soon become unable to function, desperate for help but unable to get anyone’s attention. 

   And all she needed was a sandwich or crackers.

***

   A cover-up began immediately; just after Lisa’s collapse, pages  - including the ones with the nurses’ notations quoted above - were removed from her chart; a ‘patient representative’ rudely refused to give me, her husband, any information or access to her chart without a power of attorney - which I didn’t need anyway, and which she knew I was unlikely to have - and, with Lisa unconscious, I could not obtain. 

   In the days that followed her near-death, Lisa briefly became minimally conscious, responding to simple requests, such as “squeeze my hand” -  enough to hear conversations in her room but unable to speak, so she would have known exactly what had happened to her.

***

   Lisa died on Dec. 2, 2003 in the hospital’s ICU, three weeks after she collapsed,.  A wrongful death claim filed in 2005 was dismissed after the hospital or its insurance company paid Matthew Leinung, a physician at Albany Medical Center Hospital, to testify under oath that the nurse who failed to follow the hospital’s hypoglycemia protocol did not deviate from the standard of care, and - without citing any evidence -  that Lisa’s blood glucose level when she was found semiconscious was really at a safe 80 mg/dL. (Leinung tried to hide; the resume he submitted with his affidavit made no mention of his employment at Albany Med. It didn’t work).

***

   What happened to Lisa should have shocked Samaritan’s management into taking whatever steps were necessary to insure  it would never happen again.

   It didn’t.

   Five months after Lisa’s death, another patient with diabetes, 81-year-old Alec McKenzie, died in the same hospital after nurses, despite a warning that he, like Lisa, was at risk of hypoglycemia, failed to monitor his glucose level. (The resulting lawsuit was settled two years later for $125,000.)

   Shortly after Lisa died Medicare paid the hospital almost $74,000 for treating her in its ICU for the horrific injuries it had inflicted on her.  Matthew Leinung was paid for his opinion - likely several thousand dollars - to explain away the negligence documented in Lisa’s chart.

   Lisa’s estate got nothing.

********

 What happened to Lisa in 2003 is what in 2007 was designated by The Centers for Medicare and Medicaid Services as one of 28 ‘never events,’ errors so egregious that they should never happen, If they do, the facility will not be paid for the resulting treatment.  Never event number 28 says: ‘Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility.”  If this rule had been in effect in 2003 Samaritan Hospital would not have been paid approximately $73,000  for the 21 days Lisa was in its ICU.

— David Baker

Editorial

 Hospital changed nothing

after Lisa’s untimely death

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 a low heart rate and no respiration, and 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 the next post shows, the state Health Department refused to provide details of its investigation 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 a lawsuit like that filed by Mr.  MacKenzie’s relatives would probably be reported 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.

***

Never forget

 

IN MEMORIAM: The names of Capital District patients 

who since 2003 have died from alleged medical errors.

 

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Lisa Baker, Alec MacKenzie, Lilian Cedeno (and her unborn child), George Rainville, Elizabeth Goebel, Helen Turcotte, Joan Clerk, Ruth A. Cacilla, Joseph P. Bartoski, Tara Kathleen Palmer, M.Elaine Edelson, Melissa McMohon, Thomas Jubic, Sacora Grimes, Victor Higgins, Helen Remington.

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