RIP Lisa

A sad anniversary of 

an avoidable tragedy 

By David Baker
Posted Nov. 9, 2024

On Nov. 11 it will be 21 years since Lisa lapsed into a coma after a nurse at Samaritan Hospital in Troy failed to monitor her blood/glucose level after it had dropped just below the point considered hypoglycemic.

Two hours later, it was near zero, causing catastrophic brain damage. 

Lisa died three weeks later at age 42.

With its team of lawyers fighting a wrongful death claim, the hospital avoided any responsibility for the death, even though five months later another patient with type 1 diabetes died after a nurse again failed to monitor his glucose level.

RIP Lisa. You will never be forgotten.

****

A shameful paid opinion

 

Albany Med doctor claimed that failing to treat

 low blood glucose is not a violation of the rules

Matthew Leinung’s paid opinion allowed Samaritan Hospital

 to avoid any responsibility for a diabetic’s totally avoidable death

   Back in 2008, Kathleen Ryan, a lawyer defending Samaritan Hospital in a wrongful death/medical malpractice lawsuit, needed a physician to state in an affidavit that a nurse did not depart from the standard of care when she ignored the hospital’s hypoglycemic protocol and a physician’s written order to apply it, failing for several hours to check on and treat a type 1 diabetic patient after an episode of low blood glucose.

   When the nurse finally went to the bedside, the patient had no pulse or respiration - and a recorded glucose level of just 2 mg/dL.  A code was called.  The almost dead patient was resuscitated and placed on life support.  She had received a catastrophe brain injury.  After three weeks in a coma, she died.

   Facing a motion for summary judgement, Ryan was urgently trying to find a doctor who would testify that Samaritan Hospital was not responsible for the death.  But not surprisingly, several physicians she approached declined to say what she wanted.

   Until she found Matthew Leinung  at Albany Medical Center Hospital.

   Leinung agreed to state under oath that failing to provide basic but essential care for a patient with type 1 diabetes was not a deviation from the standard of care.

   Leinung’s affidavit was all an impatient judge needed to dismiss the case.

   The hospital’s patient died - and, with Leinung’s despicable claim, it dodged being held accountable for a completely avoidable and excruciatingly painful death.

   Leinung willing betrayed his profession for cash.  It may cost him his reputation.

****

Diary of a tragedy: Lisa’s last 21 days:

http://www.capitaldistricthealthclaims.com/lisa-at-samaritan/

*******

Commentary

Use of contract ER doctors prompts questions

By David Baker
Posted July 4, 2023

      The existence of multiple legal entities employing physicians in Samaritan Hospital’s emergency room that is revealed in the William Kramek lawsuit (See story "ER staff sued" on list at right) prompts several questions:

    * Why are there so many legal entities involved in one emergency room?

   * Do any of  the entities named in the Kramek lawsuit employ more than one physician?

   * Who controls the four entities named in the Kramek lawsuit that list a St. Peters’s Health Partners facilities as its address?

   * It been reported that so called traveling nurses employed by an agency earn four times the pay of a staff nurse.  What is the cost of an ER physician working under contract for one of the legal entries named in the Kramek complaint compared to one who is a direct employee of the hospital or its owner?

   * Usually, if a lawsuit names, say, a hospital and two physicians, each will be represented by a different law firm.  But in the Kramek lawsuit, it appears that all the outside entities are represented by one law firm.  Why would this not create a conflict if there was a question of which of two physicians employer by different legal entities was alleged to be responsible for harm? 

  * What about Medicaid?  As a non-profit organization, the hospital is required to accept Medicaid rates for patients covered by the federal program for the poor.  But are the physicians who are employed by a separate legal entity also required to accept Medicaid rates in full?

   * Then there’s malpractice insurance.  Are the physicians covered by the hospital’s policy, or does each one have his or her separate coverage?

   These are some of the questions raised by the Kramer complaint.   Answers to them will likely prompt further inquiries on the staffing of St. Peters’s Health Partners’ facilities.

   Not a surprise is that the local media has been silent on this  story. A check of the Albany Times Union archives produced no story about the Kramer lawsuit or the $7.7 billion bankruptcy filing in May by Envision Healthcare Corp. the company that  provides ER doctors to emergency rooms around the country 

   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 the 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.

    What is clear is that the St. Peters management knowingly allowed an outside for-profit company to benefit from deliberately misleading people at what would often be a time of great stress and discomfort, right in its own emergency rooms.

******

Never-ending impact

Sometimes locked in silence: the 

other victims of medical errors

By David Baker
Posted June 8, 2023

   The three nurses who clocked in for their shifts on the fourth floor of Samaritan Hospital in Troy, N. Y. one evening back in November 2003 could not have imagined that the collapse of one of their patients that night would set off a series of events that is still going on 20 years later.

   The patient, who had type 1 diabetes, was Lisa Baker.  Just after 2 a.m. on November 11 she was found not breathing and - according to an entry in her medical chart - with a blood/glucose level of 2 mg/dL.

   Any reading below 60 mg/dL requires immediate treatment. 

   Lisa lapsed into a coma, her brain and other organs damaged by the lack of glucose and oxygen. She died three weeks later.

   The medical chart shows no indication that a check of her was done for the four hours after a first episode of hypoglycemia earlier in the evening - even though checking to ensure that a patient’s glucose has stabilize at a safe level is required by the hospital’s “hypoglycemia protocol”, a written instruction the attending physician had that evening ordered in a written entry in the chart to be used if Lisa’a glucose level dropped.

   That collapse, and the hospital’s refusal to acknowledge what its own records show, led to two lawsuits, one against the hospital and two doctors, the other, naming four individual staff members that was filed after the hospital refused to allow the first complaint to be amended.

   The claims were dismissed after Samaritan Hospital’s lawyers paid Mathew Leinung, an endocrinologist at Albany Medical Center, to provide an affidavit saying that the nurses who ignored the attending physician’s written order did not fall below the standard of care. This despite the medical chart showing that what happened - hypoglycemia that starts while a patient is a healthcare facility - was what Medicare later termed one of 28 ’never events’ events so egregious that they should never happen, and for which it would deny payment for treatment resulting from the event, and that Lisa’s death certificate listed as a cause of death “profound hypoglycemia,”

   But that rule was not in effect in 2003; Samaritan Hospital was paid $73,000 for treating Lisa in its ICU for the three weeks she was in a coma prior to her death. 

   The dismissal of the lawsuit prompted this blog, with its details of dozens of lawsuits against Capital District hospitals alleging deaths and serious injuries, lawsuits that the area’s media had ignored, while running endless ads for the hospitals.

   A related web page brought a lawsuit in 2012 from the hospital; an obvious attempt to suppress information about the lawsuits. The lawsuit was resolved after two years with a change of its web address. It is still up, with the new address, capitaldistrictheslthclaims.com.

  And now a book about Lisa’s case is coming, creating a near permanent record of the events surrounding Lisa’s totally preventable death.

—

   Four people are listed in the hospital records -  and were named in the second lawsuit - as being on duty in the hospital’s fourth-floor Progressive Care Unit that night. Of those, it was Mary Ann Salvana Lee, then 33 years old, who signed the chart entries relating to Lisa.

   Lee had been issued a New York nursing license just nine months earlier, on February 21, 2003, according to the state’s online listing of professional licenses. It is still current, expiring on January 31, 2026.  Lee, now 51 years old, is still living in the Albany area.

   Of the other three, Mary Kay Keller and Mary Martin have either retired or left the profession; their licenses have expired. There is no indication that the fourth person listed in the hospital’s records, Elza Villajuan, has ever held a nursing license; either her name was misspelled or she may have been a patient aide.

—

There are many ways people can unintentionally cause serious  injury or death: Leaving a child to die in a hot car;  Not securing a gun that is then found by a child who unintentionally shoots someone. 

   Or giving a patient an IV shot into her spine instead of a vein, as two doctors at Albany Medical Center Hospital did in 1985, taking the life of 21-year-old Lillian Cedeno and her unborn child. 

   And most people who make such a mistake will live with it for the rest of their life, reliving over and over the details of the event.

   Some seek relief from the guilt with alcohol.  Marriages will be destroyed.  Some people take their own lives.

   Others go into denial, refusing to admit even to themselves that they are responsible for the tragedy. 

   The first victim is the patient harmed or killed by a medical error.

   The others are first the patient’s family - and then the people who made the error, and might want to acknowledge the mistake but are left to suffer in silence by management’s routine aggressive defense of every claim that it was responsible for an injury or death in its facilities.

**********

Link

How a terrible mistake by two Albany Med doctors took two lives: https://bit.ly/3NkpgzS

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

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

   

Never forget

 

IN MEMORIAM: The names of Capital District patients 

who since 2003 have died from alleged medical errors.

 

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

Lisa Baker. Alec MacKenzie,  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.

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

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.

*****

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.

 ****

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