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.

 

********************************************

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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Final discharge

.

____________________

Lisa at Samaritan Hospital

From the archives: This post was first published on Nov. 11 2007.

On Thursday November 6, 2003, Lisa left her home for the last time.  That evening she went to the emergency department at Samaritan Hospital in Troy N.Y.because of what appeared to be a digestive problem related to her diabetes.   In the early hours of November 7 she was admitted and moved to a bed in the hospital's Progressive Care unit on the fourth floor.

After five days, Lisa's condition had improved.   On the evening of November 10 she told me one of her doctors had said she would probably be discharged the next day.

When visiting hours ended at 8 p.m. I told her I would see her the next morning.  As I left her in the care of Samaritan Hospital she said she was looking forward to coming home, and we said goodbye.

It was the last time she would ever speak to me.

 

   THE CALL CAME IN at about 2:20 on the morning of November 11, 2003. The caller identified herself as a nursing supervisor at Samaritan Hospital. "You should come over here," she said. "Lisa isn't doing too well." I told I would leave immediately. 

   What could have happened, I wondered as I drove along Route 787. Wasn't Lisa set to come home that day?  By the time I arrived at the building on Burdette Avenue I thought Lisa must have died and they didn't want to tell me over the phone.

   As I walked toward her room, a woman broke away from a small group near the door. She said she was the nursing supervisor. I think she said her name was Corinne.  "They're working with Lisa," she said, and suggested we move to a small conference room next to the area near the elevators. Lisa had collapsed, the supervisor said. She had stopped breathing and had a low heart rate.  She had been resuscitated and was now on life support. 

    And her blood sugar had been at 2.

   Two milligrams of glucose per deciliter of blood? I was stunned.  How could this have happened? A level that low would usually be fatal.  Without a constant supply of glucose, brain cells begin to die in seconds. A person can survive unharmed without oxygen for several minutes, but not without the brain's energy, glucose. 

   What Corrine didn't tell me was that earlier in the evening, just after I had left, Lisa's blood sugar had dropped to 55 mg/dL, just below what the hospital's own protocol lists as hypoglycemic, and that she had been given glucose through an IV. I wouldn't learn about that, and what had been done for a patient who was clearly at risk, until weeks later when some of Lisa's records were handed over. 

   As we talked, several staff members rolled a bed past the conference room. A thick tube was sticking out of Lisa's mouth, an IV bag was hanging from a pole.   On the bed I saw a chart and one of those plastic bags they use for patients' possessions.  "They're taking her to the ICU," Corinne said. "After they get her set up you can see her."

   Twenty minutes later I was in a room in the ICU when a very big man came in and began to check the respirator.   He said he was a respiratory therapist and had been involved in the effort to resuscitate Lisa.  "Do you know what happened," he asked. "They said her blood sugar was at 2.  It’s nice to win one but this is one we shouldn’t have won, but we did.”

   THE DOCTOR STOOD at the bedside in the Intensive Care Unit at Samaritan Hospital, where Lisa lay unconscious, and, at least for a while, able to breathe on her own.  The doctor was holding a medical chart.  And he was puzzled.  “Did this happen at home,” he asked me, referring to her collapse into a coma three days before on the hospital’s fourth floor.  “Because there is nothing in here prior to her coming into the ICU.”  Someone, it seemed, had stripped the record.  

   Someone must have something to hide.

   The doctor was Ram Agrawal.  At my request, he had taken over Lisa’s diabetes care from the endocrinologist who had been consulting on the case since Lisa had been admitted the week before.   I had made the change partly because that doctor had apparently been avoiding me, despite a request via the hospital’s ‘patient representative’ for a meeting.  Now Dr. Agrawal was the consultant for her diabetes.  And he needed information, information, which evidently had been removed from her chart.

   This was on the evening of Friday, November 14.  Earlier in the day, Lisa had been taken off the respirator and the sedation. But she was far from normal.  When I had arrived at mid morning, she was sitting up in the bed.  But she didn’t speak.  Instead, her eyes were rolled up in her head.  She was making a strange groaning sound while sticking out her tongue, holding her arms out in front of her as if reaching out to hug someone and turning her body from side to side from the waist.  Lisa’s brother had come in while I was there and he was so disturbed by what he saw that he had to quickly leave. 

   Just before I had left home, I had made yet another attempt to get information from the so-called patient representative’s office.   Earlier in the week I had been directed to the office and had spoken to a Carol Febbro.  Febbro had said she would make some calls and call me later that day at home.   But there had been no call that day, or on the Wednesday or the Thursday, even after a message was left with a secretary during another visit to the office.

    Now, on the Friday morning, my phone call was picked up. But it was not to give me any information.  Febbro’s tone was defensive, curt, almost rude.  She said that without a power of attorney, the hospital would not provide access to any of Lisa’s records or discuss her treatment with me. 

    Lisa remained semiconscious through Saturday.  According to Dr. Agrawal’s notes, she would respond to simple requests, such as ‘lie down,’ or ‘stay quiet.’   Some of the nurses had also recorded similar observations.  Lisa, it seemed, still understood language and presumably was able to comprehend her dire situation and the circumstances that had led to it. 

   ON THE SUNDAY, five days after Lisa collapsed, I took her hand and asked her to squeeze it.  She did. I asked if she knew who I was, and to squeeze once for 'yes'. A nd again I felt her grip on my hand.  It was a startling moment.  I had just heard from one of the nurses that Lisa had been responding to simple requests.  Because she had made no discernible effort to speak, I had seen no sign that she was aware of where, or even who she was.   Now I had a clear indication that she was conscious of her surroundings.  That meant that she would have heard at least some of the conversations about her condition, and about what had happened to her. I tried asking more questions, but she seemed to be tiring and stopped responding.  I told her I would try again the next day.  It was not to be.

   At around 1 the next morning a nurse in the ICU called to say Lisa's condition had deteriorated.  She had become unresponsive and was having increasing difficulty breathing. She had been placed back on a respirator.   It appeared that there had been a significant change in Lisa's condition.

   At first the nurses in the ICU were very cautious and said little about how Lisa's injury might have occurred. But after a couple of days, some of them began to reveal was evidently being said in the department and on the fourth floor:  Lisa, already borderline hypoglycemic, had mistakenly been given insulin.  Maybe someone misread the chart and restarted an insulin drip that had been discontinued the day before.   Or perhaps Lisa was given a syringe shot that was really meant for another patient.  Either way, she was now critically injured and would likely never regain consciousness even if she survived. 

   I sensed that there was both sadness and anger that someone on the hospital staff might have caused such a thing to happen.  And in the four years since then the hospital has not offered any explanation, never mind a credible one for what happened. 

   Meanwhile, one of the ICU doctors would later say that something clearly had gone wrong that night, and he hoped the family would investigate. 

   More on that in a moment. 

   The ICU staff certainly did everything possible for Lisa.  And one of the ICU nurses had actually spoken to her the day before she collapsed.  This was after several attempts had been made to insert an IV needle.  At that point someone said they should call Sharon from the ICU; Sharon would be able to start the IV if anyone could.  Sharon came up a few minutes later and got the line in at the first try. 

   Two days later, Lisa was on life support. "I work here ," Sharon said to me one day in the ICU. "and I see what happens.   I've told my husband, if you get sick, don't come to Samaritan Hospital."

   I WAS AT AN AUTO SHOP, about to pick my car after a service when the call came in on my cell phone.  It was a neurologist at Samaritan Hospital.  He had just reviewed the results of a second EEG done on Lisa.  “I’m afraid it’s not good ,” he said, speaking with what sounded like an Australian or New Zealand accent.  The test, he said, showed a significant change from normal brain wave activity.   He said based on the test, it was his opinion that there was little chance Lisa would ever regain consciousness.  Asked about the cause of this condition, he said he had no doubt that it was the hypoglycemic event of the previous week. 

   The neurologist’s findings, although not a surprise, were still a shock. This had all happened so quickly. 

   That evening at the hospital I had a long discussion about the EEG result with Lisa’s attending physician.  Based on her previously stated wishes and her current condition, we agreed that a do not resuscitate order should be place in her chart.  This would mean no steps would be taken to keep her alive if she were to have a heart attack or a stroke.  She was already had machines breathing for her and feeding her and would apparently stay that way for as long as she continued to live.  She had always made it clear that she never wanted to be forced to stay alive on a machine, if for all intents she was already gone. 

   The doctor went out to the nurses’ station to write the order and to explain it to the nurses.  A moment later I heard a female voice yelling: “No! No! You can’t do that!” I heard the doctor’s lower voice. And then the woman spoke again, still protesting a do not resuscitate order.  I recognized her immediately.  It was one of the nurses.  The last time I had seen her she was working on the fourth floor while Lisa was there.

   DURING THE SECOND WEEK of Lisa's time in the ICU, an event occurred that affected her family almost as much as the horrific injuries she had received while in the care of the hospital.  On the Thursday, Lisa's parents come in to see her for the first time since she had collapsed.  Her father in particular was having a hard time dealing with the sudden change in his daughter's condition.  By this time Lisa was totally unresponsive and the sight of her hooked up to the respirator and other machines was clearly distressing.  It had taken him more than 40 minutes after he arrived at the hospital to steel himself to walk into her room.

   Just hours after the visit, Lisa's mother started having chest pains.  She was rushed to Albany Medical Center Hospital.  The doctors discovered and treated a blockage of the arteries to the heart and she was able to go home several days later.   But for a time Lisa's father was facing the real possibility of losing his wife of more than 60 years and his youngest child in the same week, perhaps in the same day.

   Meanwhile, Lisa remained unconsciouses, with little change in her condition.  At the beginning of the week I had asked the attending physician if she could be transfered to another hospital.  I was alarmed by the missing records and the refusal of the hospital's management to give me any information about Lisa's collapse.  It was obvious they knew what had happened and that they didn't want me to know.

   But the doctor said a transfer would be risky and could not be justified medically.  So, reluctantly, I agreed to keep her at Samaritan Hospital. I was still working a split shift and was in the ICU several times each day, some times before 6 a.m., sitting at her bedside with the steady rhythmic hissing of the machine that was keeping her at least nominally alive.

  Week 3 

   FOR SOMEONE WHO HAD HAD DIABETES for 30 years, Lisa's kidneys were in remarkably good condition.  A common complication of the disease is damage to the organs that filter waste from the blood. Lisa's kidneys, though, had continued to function well and tests done just after she was admitted to Samaritan showed that both her creatinine kinase and BUN (blood urea nitrogen) levels were close to the normal range.  But that had changed by the third week following her collapse.  A nephroligist, Dr. Leslie Goldstein - one of a half-dozen specialists who were treating Lisa - told me her kidney function was declining, and that he thought that by the middle of the following week she would be on dialysis. 

   And Dr. Goldstein said he had no doubt that the change was the result of the near-zero glucose level that had occurred on the night of November 11.

   Dr. David Strumpf, a pulmonary specialist who worked in Samaritan's CCU, explained that the damage was not limited to Lisa's kidneys.  All her vital organs were affected, he said, and the result was a downward spiral as the decline of one put stress on each of the others. 

   Dr. Strumpf also said he believed the damage was the direct result of the lack of glucose that had occurred on the hospital's fourth floor on the night of November 11. 

   On the Friday, at my request, a third EEG was done.  After it was completed the neurologist said it showed even less brain activity than had been found by the second one.  He also said Lisa lacked what is known as the 'doll's eyes' or oculocephalic reflex.   The absence of this reflex, he said, strongly indicated that the brain stem was damaged, which was consistent with her inability to breathe on her own.

   I also noticed that Lisa's arms were straight at her sides, with the palms turned downward and out instead of facing the body, a condition I was told is known as decerebrate posturing, a strong indication of brain-stem damage.

   I discussed the situation with Lisa’s brother. He had been in contact with Lisa’s two sisters, and with her mother and father.  All except her father agreed that Lisa would not wish to be kept living on life support. Lisa also had said repeatedly she didn’t even want to be on dialysis.  Only her father had continued to believe that his youngest child might recover.

   But by the weekend of November 29/30 he had accepted that even if Lisa did not die from organ failure, she was never again going to be Lisa.  He accepted what she had also told him: that she did not want to be a vegetable kept alive by a machine.

   IN THE EARLY AFTERNOON OF DECEMBER 1, Lisa's brother and one of her sisters met me at the hospital.  We were there to discuss the situation with Dr. Strumpf.  The hospital wanted us to sign a statement saying Lisa had told us she would not want to remain on life support if there was little hope of regaining consciousness, and that we were not opposed to removing the respirator.  The statement was clearly intended to protect the hospital from a legal claim. 

   As the statement was being drafted, I recalled how just a couple of months earlier thee had been a story on TV about Terri Shiavo, the Florida woman whose husband was trying to take her off the feeding tube she had been on since she had become unresponsive after a heart attack in 1990.  I asked Lisa what she would want me to do if she were to be on life support with no hope of recovery.

   "That's not going to happen to me," she said.  But what if it does, I said.  By then, you won't be able make the decision.  "I wouldn't want to be kept alive by a machine," she said.  Then after a short time, she turned to me and said "Promise me you won't let let them keep me alive like that."

    I told her we should get the proper form signed and witnessed. But it was put aside and had not been completed when Lisa went to Samaritan Hospital on November 6.

*****

   After the statement was signed, Dr. Strumpf told us he was disturbed by what had happened on the fourth floor three weeks earlier.  “I was not involved with it,” he said.  “But for your own peace of mind, I hope you folks will investigate.  This should not have happened. Something went very wrong up there.”

***** 

    That afternoon Lisa's respirator was removed. At 5:46 p.m. on December 2, 2003 and with me at her side, she died. 

*************************************** 

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*****

ER staff sued

 Alleged spinal injury brings lawsuit

 against Samaritan Hospital

By David Baker

Posted June 5, 2023  

   A Rensselaer County man who went to the emergency room at Samaritan Hospital in Troy, N.Y. with stomach pain and vomiting has filed a lawsuit alleging that he was damaged when a tube that was passed through his nose into his stomach allegedly causing spinal fluid and air to enter his brain.

   The patient, William Kramek, was then transferred by ambulance to Albany Medical Center Hospital, where a patch was placed to stop the leak of spinal fluid.

   The complaint says that “..as a result of defendants’ negligence, Plaintiff was cause direct trauma from insertion of the nasogastric tube resulting in him becoming diaphoretic [sweating excessively], eyelids dropping, seizure activity and leaking cerebral spinal fluid through his nose.”

   The complaint names Samaritan Hospital, St. Peter’s Health Partners - and 10 entities that provide physicians under contract to work in emergency rooms, some of the entities apparently owned by the hospital operator itself.

   The lawsuit was filed on May 31, 2022 but is now on hold  after one of the contracted entities, Envision Healthcare Corporation, filed for Chapter 11 bankruptcy protection in May, reportedly owing $7.7 billion to dozens of other organizations. 

   The filling comes five years after Envision was taken private by the private equity group KKR in a deal valued at $10 billion.

   In addition to Envision Healthcare Corporation the complaint lists as defendants two other entities that appear to be associated with and perhaps owned by Envision Healthcare and share the same Florida address: Envision Physician Services, LLC; and Emergency Medical Association of New York P.C. 

   Another two entities under contract with the hospital, Emergency Medical Associates and Emergency Medical Associations PLLC, share an address in Parsippany, N.J. One of them appears to have been set up by a doctor, Stanley W. Docyk of Ballston Spa, N.Y., which then contracted to provide Docyk’s, services to the hospital.

  Four of the 10 corporations are apparently owned and operated by St. Peter’s Health Partners: St. Peter’s Health Partners Medical Associates; St. Peter’s Health Partners Emergency Associates; and Manning Emergency Medical Associates all list 315 S. Manning Boulevard in Albany - the address of St. Peter’s Hospital - as their address. Another defendant, Emergency Medicine Physicians of Samaritan, PLLC, lists 2215 Burdett Ave. in Troy - Samaritan Hospital’s location - as its address.

   Press reports on Envision’s bankruptcy filing suggest passage in 2020 of the federal No Surprises Act impacted Envisions’s revenues. The act restricts how doctors who work in a hospital but are employed by an agency can bill patients whose insurance was not accepted by the outside physicians. Before the passage of the act patients who often had no idea that the doctor treating them was not an employee of the hospital and did not accept their insurance were getting billed for thousands of dollars - and getting sued when they were unable or unwilling to pay the surprise bill.

   The lawsuit, which also name Kramek’s wife Anne as a plaintiff,  was filed by the Troy law firm E. Stewart Jones Hacker Murphy. 

  Representing Samaritan Hospital, St. Peter’s Health Partners and St. Peters’ Health Partners Medical Associates is  the Albany firm Thorn, Gershon Tymann & Bonanni. 

   Manning Emergency Medical Associates PLLC, Envision Healthcare Corporation , Envision Physician Services LLC, and Emergency Medial Association of New York are represented by O’Connor, O’Connor, Breese & First of Albany.

   A check of the Albany Timers Union archives produced no story about the Kramer lawsuit. As has been reported on this page, TU publisher George Randolph Hearst III has a seat on the St. Peter’s Health Partners’s board and has raised millions of dollars for the company. 

   Over past 26 years the paper has ignored dozens of lawsuits alleging wrongful death and serious injury filed against hospitals and other facilities now operated by St. Peters Health Partners.

****

George Randolph Hearst: Opinion: A duty abandoned. 

Physicians' hidden employers

 In this ER, the doctors don't work for the hospital

   For years, hospitals and nursing homes have filled open nursing shifts with people from staffing agencies. A nurse might work a singe shift or cover it for a week. But the rest of the nurses would be employees of the facility.
   But, as the complaint described in the story above reveals, at Samaritan Hospital in Troy, most, if not all the physicians in its emergency room are employees not of the hospital but of a separate legal entity.
   And not just one agency. In the lawsuit filed by William and Anne Kramek, there are 10 legal entries listed as defendants. Five of them appeared to be wholly owned by one company, Envision Healthcare Corporation.
   And more puzzling is that another four are evidently creations of St. Peter’s Health Partners - which owns and operates another of the defendants, Samaritan Hospital, where William Kramek alleges his injury occurred. 
    In May, citing debts of almost seven billion dollars, and after missed an interest payment, Envision Healthcare Corporation filed for protection under the bankruptcy laws. The company says it will continue to operate during the bankruptcy proceeding. 
   Not clear is why a hospital a would have some, maybe all its emergency room physicians employed by a separate legal entity. And if, every unwell person who arrived St. Peter’s Health Partner ERs prior the implementation of the No Surprises Act was told and clearly understood that their health insurance might not be accepted by the entity paying the physician, and that they, the patient, would be responsible for physicians’ bills.

—David Baker

   

Justice denied

Answers for Lisa:

 First the web page. Next: the book

The extraordinary story of one avoidable hospital death and

 the people who helped those responsible avoid accountability 

By David Baker

   This year it is two decades since my wife Lisa Baker’s totally avoidable death while she was in the care of Samaritan Hospital in Troy, N.Y. 

   For the hospital’s management, it was just another medical malpractice claim for its attorneys to fight. Then it was over. The hospital took the $73,000 it was paid to treat Lisa in its ICU for the ultimately fatal injuries she had received at its hands and moved on; another plaintiff  beaten off by an army of lawyers funded by an immensely wealthy insurance company.

   While nothing can bring back a person whose life is taken by a hospital’s negligence, when it happens most family members want two things; first, a full explanation of what happened

   And second, an assurance that it will never happen again.

   But in Lisa’s case no credible explanation has ever been offered. Rather, the hospital repeatedly claimed that even some entries in its own records were wrong, such as Lisa’s almost non-existent glucose level when she was found in her hospital bed near death. 

   And as for never happening again: Just five months after Lisa died, another Samaritan patient, Alec MacKenzie - who also had diabetes - died after once again nurses ignored a physician’s specific order that they follow the  hospital’s written instructions if MacKenzie’s blood glucose level dropped.

   But with no acknowledgement that the hospital staff had caused a patient to lose her life - and, therefore, no assurance that steps would be taken to prevent it happening again - there has been no moving on for me.  Add to that the extraordinary events surrounding the legal claim against those responsible for Lisa’s safety and the matter is still open, as painful now as it was in 2003.

   So the law didn’t hold them accountable. But I can - with an almost permanent account of what happened. 

   I am writing a book.

   Sites on the internet can disappear. But paper books are distributed to and can remain in homes, libraries and on-line book stores for decades. (All four of my mother’s books can still be purchased, via the internet, more than 60 years after the first one was published.) 

   Here then is a summery of the main players in the saga that is Lisa Zenzen Baker vs Samaritan Hospital -  that also led to the publication on my web page and this blog of stories about dozens of lawsuits filed against Capital Region medical providers that since 1998 the area’s media outlets have ignored to protect a steady stream of revenue from some of their biggest advertisers.

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Matthew Leinung. A doctor at Albany Medical Center Hospital who provided an affidavit in support of Samaritan Hospital’s motion for summary judgement dismissing the lawsuit, in which he stated that nurses who ignored a physician’s written order to follow the hospital’s printed protocol for treating hypoglycemia did not depart from the standard of care.  He also claimed to know, four years later, that Lisa’s blood-glucose level when she was found in her hospital near death was actually a safe 80 mg/dL - not the 2 mg/dL recorded in her medical chart.  This despite that fact that Lisa was immediately treated for low blood glucose, and that her death certificate listed as a cause of death, “profound hypoglycemia.” Leinung’s extraordinary paid opinion allowed the hospital to avoid any responsibility for Lisa’s totally avoidable and excruciatingly painful death. 

Cynthia LaFave.  Incompetent attorney who took on but later abandoned without notice Lisa’a wrongful death claim.

 

Stephen Coffey.  A lawyer at the Albany law firm O’Connell & Aronowitz who called and offered to consider taking over Lisa’s lawsuit from LaFave without disclosing that his firm was representing Samaritan Hospital, then embarked on a calculated effort to get the claim dismissed. He later wrote an angry response to my detailed letter describing his efforts to destroy the case as ”…an assault on me and my office.”  But his letter didn’t deny or even address the accusations against him. 

James K. Reed, M.D.  Former president and CEO of St. Peter’s Health Partners and before that CEO of Northeast Health prior to its merger with SPHP.  During his tenure hundreds of lawsuits alleging avoidable deaths and injuries were ignored by the Times Union while the newspaper ran a steady stream of ads for the healthcare companies. It was during Reed’s time in charge that, five months after Lisa Baker was fatally injured when nurses ignored a physician’s direct order to apply written  instructions for treating hypoglycemia that another patient with diabetes, Alec MacKenzie, died when nurses again ignored a physician’s order to use the instructions, revealing Reed’s callous disregard for the safety of patients in his hospital that bordered on the criminal. 

Akiva Abraham.  Former gynecologist, sued by a patient who made the unusual claim against Samaritan Hospital of ‘negligent credentialing’, alleging that the hospital granted and repeatedly renewed Abraham’s privileges despite overwhelming evidence that he was medically and morally unfit to practice.  The lawsuit, settled in 2012 after six years of litigation, alleged that Abraham performed an unnecessary procedure he was not authorized by the hospital to perform on the patient’s breast without her knowledge or consent that left her disfigured. The lawsuit was never reported by the Times Union, even as it published a dozen stories about Abraham’s arrest and conviction for insurance fraud stemming from an arson; his bankruptcy filing; and the revocation of his medical license.

Stephen Ferradino. State Supreme Court judge who made no effort to hide his basis against a self-represented litigant, refusing to order Samaritan Hospital’s attorneys to produce a highly relevant medical record that could have changed the outcome of the lawsuit that clearly was being withheld.  Self-represented, litigants  are usually afforded extra latitude but not in Ferradino’s court: During a conference in chambers and over my objection he gave the hospital’s attorneys far more time to respond to a motion than they had asked for, while, on another issue, strictly enforcing the rules on me.  Ferradino retired in June 2014 after 20 years as a state Supreme Court justice.  He died in July 2022.

Kathleen M. Ryan.  Attorney defending Samaritan Hospital. During a conference in the judge’s chambers, Ryan said her clients were prepared to settle the lawsuit. Before doing so, though, she said the insurance carrier wanted a “final review.”  But as later became apparent, that was a lie to buy time; the weeks-long delay was really so Ryan could continue looking for a doctor who would provide an affidavit in support of a motion for summary judgment dismissing the claim.  Evidently, none of those she had approached were prepared to say what Ryan wanted. Until Matthew Leinung of Albany Medical Center Hospital, disregarding the most basic care required for a patient with diabetes, agreed to make the outrageous claims described in the first item above.

George Randolph Hearst, lll, Publisher and CEO of the Albany Times Union, who raised millions of dollars for St. Peter’s Health Partners. He was then appointed to a seat on the hospital operator's governing board, which in 2011 named an addition to its main Albany hospital the Hearst Pavilion.

Rex Smith. Editor of the Times Union from 2002 to 2021, and before that managing editor, news, years during which the paper ignored dozens of medical-malpractice lawsuits against a hospital operator that ran a constant stream of ads in the paper.  Smith did not respond to requests for comment on this glaring abandonment of journalist ethics.

New York state Department of Health.  After a staff member initially said in a phone call responding to a letter describing what had happened to Lisa in the early hours of November 11, 2003 that there appeared to have been serious negligence, the agency later turned the file over to an outside organization for a review.  And apparently using only the medical chart - no interviews of those involved - the anonymous reviewer dismissed all the evidence of negligence in a single paragraph - a decision that shocked at least one staffer in the DoH office in Troy.  But the department was overruled; case closed.  And efforts to get more information on the outside organization’s stunning determination met a brick wall. Even Richard Gottfried, then chair of the state Assembly health committee, could get no answers.  And Kemp Hannon, then chair of the Senate’s health committee, didn’t even try.

So for Samaritan Hospital, no penalty, not even a slap on the wrist.

Five months after Lisa’s death, another patient died in Samaritan after documented negligence shockingly similar to that which had cost Lisa her life - making the state health department partly responsible for this second avoidable death.

Gloria Cooper. Trudy Lieberman. Greg Marx.  The emails tell the story.  In 2006, Cooper, then deputy executive director of the Columbia Journalism Review, respond to my correspondence by asking for and receiving extensive printed material from me documenting the absence of news in Albany media about lawsuits filed against medical facilities that were big advertisers  - and then, without explanation, abandoned the story.  Nine years later, Trudy Lieberman, a CJR contributor, also responded to my email, and did two brief telephone interviews with me and was given links to the dozens of stories about medical malpractice lawsuits by then on my web pages, but made excuses for three and a half years  - and never published a single word. Finally CJR staff writer Greg Marx suggested that a comparison with news coverage in other cities was relevant, rather than how the Albany media handles similar claims against advertisers and non-advertisers - such as jails. He, too, showed no further interest  - and CJR has never mentioned this wholesale suppression of news, the publication of which is clearly in the public interest.

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A publication date for my book will be announced here and posted on social media.

Infant injured

Lawsuit alleges wrong shot

given to newborn baby

By David Baker

Posted Dec. 22, 2022

   The parents of a baby born in St. Mary’s Hospital in Troy in 2010 have filed a lawsuit alleging a nurse gave the child an injection of Methergine, which is given to a woman to stop bleeding after childbirth, instead of a routine shot of vitamin K.

   The wrong shot allegedly caused permanent injuries, pain and suffering.

   Because the chid survived, this page is withholding the identity of her and her parents.

   Named as defendants are the hospital; St. Peter’s Health Partners; Samaritan Hospital; Seton Health System - which operated St.Mary’s at the time; a doctor, Melinda Mantello; and Clifton Park Pediatric Center, where Mantello was employed.

  According to the complaint, Dr. Mantello failed to recognize the symptoms of the negligently injected Methergine, and to promptly transfer the child to an intensive care unit for treatment of the incorrect shot.

   The complaint was filed in May 2020 by Martin, Harding and Mazzotti of Latham, N.Y.

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   St. Peter's Health Partners CEO James K. Reed is retiring at the end of the year after more than three decades in various positions with the healthcare company, and people in the organization are singing his praises. But during his tenure, lawsuits prompted by dozens of preventable deaths and injuries were ignored by Capital Region newspapers that ran countless ads for the St. Peter’s Health Partners and its predecessor company, Northeast Health.

   Coming up: A look at the consequences, on patients, their families and the public of that unhealthy alliance.

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