Another preview from the book

Lisa Baker at Saramaritan Hospital

The extraordinary story of an avoidable 

hospital death and the people who helped

 those responsible avoid accountability

By David Baker   

Posted July 13, 2026

   On the day after Lisa collapsed, members of Samaritan’s management would likely have held a meeting to examine Lisa’s medical chart.

   It wouldn’t have taken them long to see that Marie Martin, one of the nurses responsible for Lisa’s care in the hours before she was found unconscious and near death, had failed to follow the hospital’s written instructions for treating hypoglycemia - instructions that one of Lisa’s physicians had ordered with an entry in her chart the previous afternoon —  to be used if Lisa’s blood glucose level fell below 60 mg/dL. The people at that meeting would know from a single page in the chart that the hospital was responsible for the horrific injuries to a patient who was scheduled to go home that day but instead was in the hospital’s ICU on life support.

   They also would have seen that Maryann Lee, the nurse who took over Lisa’s care from nurse Martin, apparently had not examined Lisa’s chart, or conferred with the nurse she was replacing. — a  routine proceedure called “taking report.”  If she had, she would have known that one of her patients was at serious risk. As it was, she didn’t check on Lisa for over two hours, and then only when a low-heart rate monitor alarm sounded and she called a code after finding Lisa near death. 

   Now those managers had a decision to make.

   They could have decided on full disclosure; explaining what had happened and assuring me that steps would be taken to prevent it ever happening to someone else. 

   But that’s not what the cruel, callous members of the Catholic-based Samaritan Hospital’s management did. Instead, they immediately began a coverup, removing from Lisa’s chart pages documenting the treatment she received in the hours before she was found near death, and stonewalling my questions about what had happened. 

  So later, with a lawsuit pending, Samaritan’s managers were desperate to avoid responsible for Lisa’s catastrophic injuries and subsequent death.

   How desperate? So desperate that the defendants lawyers apparently conspired with high-profile Albany attorney Stephen Coffey to get the case thrown out. This was after attorney Cynthia LaFave, who was representing me but had abandoned the case without telling me.

    Now I was trying to find another  attorney. Nobody wanted it.   Then Coffey, who’s firm, O’Connell & Aronowitz, had already declined the case, called me, offering to review the file with a view to assuming representation. It seemed too good to be true. 

   It was. What Coffey and his colleague Brendan Tully actually did, in a gross violation of legal ethics, was to try and run out the clock so that a motion by the defendants’ lawyers to dismiss the case for failure to prosecute would be granted.

  The judge had instructed Coffey to a send letter to the court, with copies to the defendants’ attorneys, stating that he was considering taking the case. Coffey didn’t send the letter until after a deadline imposed by the judge had passed. The case was not dismissed but only because I filed an affidavit saying I would represent myself — something Tully, in a phone call the day before the deadline, tried to persuade me not to do. 

   How desperate? So desperate that they paid Matthew Leinung, a doctor at Albany Medical Center Hospital, to claim in an affidavit that nurses who ignored the hospital’s printed instructions on treating hypoglycemia did not fall below the standard of care, and, without citing any evidence, that Lisa’s glucose level when she was was found near death was a safe 80 mg/dL, not the near-zero level recorded by nurse Lee in the chart.

   How desperate? So desperate that they withheld at least two documents; the one from Lisa’s chart created by nurse Marie Martin in the hours before Lisa was found nearly dead and another one, called a ‘consultation note’, that would have been dictated by Dr. Rajinder Jain - a diabetes specialist who had ordered the printed hypoglycemia protocol to be used - and who was heard the morning after Lisa collapsed loudly proclaiming that what had happened to Lisa was all the fault of  “the stupid nurses.” If Jain had expressed any such opinion in a final consultation note the case would likely have been over. The hospital would have lost.

   Jain stated under oath that he didn’t dictate any consultation notes about Lisa’s care. Several months later, one of the notes he “didn’t dictate” showed up in a second copy of Lisa’s chart.

    How desperate? So desperate that the defendants’ lawyers repeatedly claimed that Lisa and were divorced when the lawsuit was filed - which would have meant I would not have been illegible to file the claim.

    Married in 1985, we were never divorced.

   How desperate? So desperate that Kathleen Ryan, one of the hospital’s attorneys, flat-out lied to me, saying  the hospital’s malpractice insurance carrier wanted to settle the case, but first needed to do a “review’ of  the medical records, — records that had been in its possession for three years. What she really was doing for several months was searching for an unscrupulous, ethics-free doctor who could be paid to explain away the gross negligence documented in Lisa’s chart. She eventually found one — Matthew Leinung  — who submitted the affidavit described above. Which got my claim dismissed. 

   Lying. Withholding documents. All in a day’s work for an attorney representing a hospital management desperate to deny its documented responsibility for the horrific and totally avoidable death of one of its patients.

Pain and Suffering

 A third excerpt from the book:

Justice for Lisa

The extraordinary story of one avoidable 

hospital death and the people who

 helped those responsible avoid accountability

David Baker

   Five months after Lisa’s death, another patient also with diabetes died in the same hospital in shockingly similar circumstances.  Once again, a nurse failed to monitor the patient’s glucose level after an episode of hypoglycemia.

    Members of Samaritan Hospital’s management had learned nothing from what they had done to Lisa.

   Or maybe they just didn’t care.

    But Samaritan Hospital’s response to the two cases was very different:  The lawsuit filed by the family over the second patient’s death was settled just over a year later with minimal litigation for $125,000. (Which was five times the amount — $25,000 —  that at one point Samaritan Hospital offered me to settle:  I turned it down). 

   In Lisa’s case, the hospital’s management was desperate to avoid acknowledging the mistake that took Lisa’s life.

   Its lawyers repeatedly claimed that Lisa and I were not married at the time the lawsuit was filed - meaning I would not have been eligible to sue the hospital  Then, faced with my motion for summary judgment, they paid Matthew C. Leinung, a doctor at nearby Albany Medical Center Hospital, to provide an affidavit stating it was his opinion that a nurse who failed to follow specific written instructions on treating low blood glucose did not deviate from the standard of care.  It was all the impatient judge needed to dismiss my claim. 

   So what was the difference between the two cases? 

   In four words: Conscious pain and suffering.

   In the medical records of the second death, there is no indication the patient was aware of the drop in his blood glucose level; he became unconscious and died.

  In Lisa’s case, it’s clear she knew that without a source of glucose she was going to die.

   She always was aware when her blood-glucose level was dropping.  The shear terror she would have experienced that evening before being found in her hospital bed near death can hardly be overstated.

  Here’s how I described visiting Lisa the day she collapsed:

   “When I arrived in Samaritan Hospital’s ICU a few hours after Lisa had been found near death, she was sitting up in the bed.  But she was far from normal.  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.”

   It’s an image that will be with me until the day I die.

   The lack of glucose had caused catastrophic damage.  Her brain cells were slowly dying. She was later placed on life support, where she remained until she died.

   But for a week or so she was minimally conscious. She would respond the doctors’ and nurses’ requests, such as “lie still, or “sit up’. She understood spoken words and so would have been acutely aware of her dire situation.

***

   In many claims for wrongful death there are two elements of a jury award or a pre-trial settlement   One is for economic damages: the amount the victim would have earned over his or her expected lifetime,  as well medical and other expenses. 

  The second - and often the far larger amount — is for conscious pain and suffering and fear of imminent death.

  In the second case in Samaritan Hospital there was no indication of the patient’s conscious awareness of his impending death.

   In Lisa’s case, the evidence is overwhelming.

    And that is why the management of Samaritan Hospital was desperate to defeat my claim for Lisa’s wrongful death.

  They got my claim dismissed.  But they are left with the outrageous claims made by that doctor at Albany Medical Center Hospital on their behalf, permanently available in a  public record.

   And now, this book.  Lisa, and how Samaritan Hospital’s management dodged responsibility for taking her life, will not be forgotten. 

******

A doctor's outrageous claim

 Here’s another extract from the book:

Answers for Lisa

The extraordinary story of one avoidable hospital death and the people who helped those responsible avoid accountability

David Baker

********

   In October 2008, Saratoga County Supreme Court Justice Stephen A. Ferradino dismissed my wrongful death claim against Samaritan Hospital and four nurses after the hospital paid Dr. Matthew Leinung at Albany Medical Hospital to provide an affidavit stating that the hospital was not responsible for Lisa’s catastrophic brain injury and subsequent death.

    But one of the claims Leinung made in his affidavit goes to the heart of the wrongful death claim, and is truly astounding. That he would make this statement in a sworn affidavit should question his fitness to ever have practiced medicine.

   The allegation in the lawsuit was that the hospital staff had failed to properly treat an episode of hypoglycemia -- low blood glucose -- by neglecting to follow up a quick acting carbohydrate with a longer lasting protein, such as bread or cheese and crackers. Without that, blood glucose will rise immediately from the danger level but then rapidly fall.

   Entries made in the medical chart by the nurse treating Lisa that evening, show that she did not give her patient the required protein.  

   Four hours later Lisa was found unresponsive with a blood-glucose level recorded in her chart at an almost non-existent  level of 2 mg/dL (2 milligrams of glucose per deciliter of blood).

   Explaining away this fact, Leinung, without presenting any evidence, then made the following extraordinary claim:

  “Although defendants’ standard hyperglycemia protocol recommended that 1 protein should follow the administration of  juice, I can state with a reasonable degree of medical certainty that the administration of protein is no longer the standard of care for the treatment of of hypoglycemia. Therefore, defendants’ failure to follow the administration of carbohydrates with 1 protein according to its protocol is not a deviation from the standard of care.”

   The hypoglycemic protocol was a printed document. The issue  current at the time of Lisa’s November 2003 admission to Samaritan Hospital was created on Dec. 10, 1997 and revised on Sept. 17, 2002 — 14 months before Lisa was found in her bed at 2 a.m., “unresponsive” and near death.

   On page 2 of the three-page protocol is the following instruction for treating moderate hypoglycemia (emphasis added).

“Give 15 grams simple carbohydrate i/e, 4 oz juice, skim milk or three tabs. Retest in 20 minutes. Repeat above treatment if symptoms persist and/or glucose is (less than) 60 mg/dL

  “If more than 1 hour remains before next meal [it did],  follow up above treatment with 15 grams complex carbohydrates and one protein serving: 6 oz milk with 3 graham crackers or 1 oz cheese with 6 saltines.”

   That’s what’s Lisa’s nurse should have done. But according to her own entries in the chart, she didn’t do it. 

  This nurse also was failing to comply with a doctor’s specific order; a telephoned instruction from Dr. Rajinder K. Jain, written into Lisa’s chart the previous afternoon that said:  “Follow hypoglycemia protocol if patient comes hypoglycemic.” 

   Apparently Dr. Jain, the consultant for Lisa’s diabetes, was unaware that the standard treatment for hypoglycemia specifying that a protein be given had been abandoned.

   But after acknowledging Dr. Jain’s order in his affidavit, Leinung then states that the nurse who ignored the protocol and Dr. Jain’s order to apply it was not negligent because “…the protocol itself did not set forth the standard of care.” 

  So Leinung claims that the hospital’s management was partly responsible for the death, suggesting that only having detailed hypoglycemia treatment instructions in the protocol was not sufficient for the nurse to know how to treat her vulnerable patient.  

   

   The only conclusion to come from all of this is simple: Samaritan Hospital killed Lisa Baker, then went to extraordinary lengths to escape responsibility for her totally preventable and excruciatingly painful death, steps that included paying an unethical doctor at Albany Medical Center Hospital to state under oath whatever Samaritan Hospital’s management wanted the judge to see.

***

Story of a tragedy

 Coming soon:

 Answers For Lisa: The book.

A sample

 

By David Baker
Re-posted July 5, 2025

Introduction

   Every year, thousands of people lose their lives as result of preventable medical errors.  In 2000, the Academy of Medicine in its report To Err is Human estimated that in the United States at least 48,000 and as many as 98,000 patients die each year.

Twenty years later, another study found that very little had changed.

   This is the story of one of those deaths.

   It’s the story of a nurse who ignored a physician’s direct, written instructions and the hospital’s printed protocol in treating an episode of hypoglycemia  - low blood glucose - in a patient with diabetes.

   It’s the story of how that patient would have experienced the shear terror of knowing that her blood glucose was dangerously low and that without help she was going to die.

   It’s the story of how pages documenting what had happened were removed from the patient’s chart.

   It’s the story of a doctor at a nearby hospital who was paid to state under oath that the nurse who, in ignoring those instructions, did not fail to meet the standard of care - even though the patient received a catastrophic brain injury and died as a direct result of the nurse’s negligence.

    It’s the story of a hospital management that for three years fought a claim of wrongful death, insisting that its own medical records documenting a near-zero glucose level were wrong, and, how the testimony of that doctor was all an impatient judge needed to dismiss the entire claim. 

   It’s the story of how, just five months later, another patient with diabetes died in the same hospital in shockingly similar circumstances.

   It’s the story of a lawyer who took the case - then abandoned it without notice.  And how another, high-profile attorney called offering to take a look at the claim, then tried  — and nearly succeeded — in getting it thrown out of court.

   It’s the story of a local media that has ignored dozens of lawsuits against the area’s medical facilities —  some of them reported in the book as they should have been in a newspaper — while running endless ads for those facilities.

   Above all, this is the story of a horrific death at the hands of a hospital management that puts its public image above the safety —even the lives — of patients in its care.

*****

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 in 2027.

Hospital’s failure to provide basic care caused 

death of patient with insulin-dependent diabetes

  

By David Baker

Posted on Jan. 7, 2025

  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 acknowledged 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 9 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, 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 (sic) 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 15 years' employment at Albany Medical Hospital).

***

   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