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

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.

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

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 two 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 Marie 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 lives, 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.

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