Lisa Zenzen Baker, 1961-2003

E-mail: answersforlisa@hotmail.com

Tuesday, September 15, 2009


Hospital gets state slap on the wrist

for second diabetic patient’s death


By David Baker
Posted Sunday, June 6, 2010

The state Health Department cited Samaritan Hospital in the death of diabetic patient R. Alec MacKenzie, who died in the hospital in July 2004, but the hospital only had to respond to a “statement of deficiencies.” It was assessed no fine, and last month the department, in response to a Freedom of Information Law request, stated that it has no record of any investigation or disciplinary action in MacKenzie’s death.

But a letter from the Troy office of the Department to the hospital dated November 8, 2004 – a copy of which has been obtained from MacKenzie’s family – says that that hospital must prepare and submit a ‘Plan of Correction, which will “…include a requirement that hospital admitting physician consider the physician orders written for patients before hospitalization.”

There is no indication that any other response other than to undertake to do what would seem to be a standard procedure was required as a result of the death, and there is no record of any fine or other penalty.

According to legal papers, MacKenzie, who was 81 and had insulin-dependent diabetes, died after nurses at Samaritan failed to properly monitor his blood glucose levels. The negligence alleged in his care is almost identical to that which, according to the hospital’s own records, had preceded Lisa Baker’s death just six months earlier.

Lisa had been a patient on the hospital’s fourth-floor Progressive Care Unit when she was found at 2 a.m. with no pulse or respiration and a blood glucose level of just 2 mg/dL. She lapsed into a coma and died three weeks later.

In 2007, the hospital settled a lawsuit brought by relatives of Alex MacKenzie for $125,000.

In Lisa’s case, the Health Department declined to cite the hospital, declaring in a three paragraph statement that her care was “appropriate.” A lawsuit was later dismissed after a doctor at Albany Medical Center Hospital stated in a sworn affidavit that nurses who failed to obey a doctor’s written order to follow the hospital’s own printed protocol for treating hypoglycemia had not failed to meet the standard of care.

The Health Department records on the MacKenzie death also include a copy of a letter in which a relative of Alec MacKenzie complains that soon after the death, the hospital sent a letter addressed to Alec Mackenzie asking for his opinion on his care in the hospital. As was reported here at the time, this is exactly what the hospital did just after Lisa died. A letter complaining about this insensitive action received no response.

And in each of the following three years after Lisa died, the hospital’s fund-raising foundation sent a letter addressed to Lisa asking for money. Six years later the letters continue to come even after repeated separate written requests were made asking that Lisa’s name and her address be removed from all its lists.

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Monday, September 07, 2009

COMMENT



Hospital changed nothing
after Lisa’s untimely death


By David Baker
September 7, 2009


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 no pulse or respiration, and, after CPR was performed, 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 an earlier post on this page shows, the state Health Department refuses to provide details of its investigations 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 details of lawsuits like that filed by Mr. MacKenzie’s relatives would probably be published 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.

The new page is expected to be launched later this year.
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Money IS an object


Medicare liens can block
even strong legal claims


Of the $125,000 paid by Samaritan Hospital to settle the MacKenzie lawsuit, $13,000 went to reimburse the insurance company that had paid for his medical care from the time his was injured to his death.

That’s because federal law says any money obtained in a liability lawsuit must first go to reimburse the health insurer for the cost of treating injuries resulting from the negligence.

In both Alec MacKenzie’s and Lisa’s Baker’s case, it was Medicare.

This law can often be an obstacle to settling a lawsuit, even when there is clear evidence of liability. In Lisa’s case, the cost of her medical care from the time she was found with – according to the hospital’s own records - a glucose level of just 2 mg/dL to when she died three weeks later was $81,078, most of which – $73,851 – went to Samaritan Hospital.

At one point, the hospital’s lawyers tried to settle Lisa’s claim for $25,000. But they refused to accept that they also would have to reimburse Medicare for the almost $82,000 paid to the hospital and the dozen or so specialists who treated Lisa in the ICU. Despite a lower settlement demand, they flatly rejected attempts to negotiate a resolution of the case

Meanwhile, Medicare refused to discuss a possible settlement of its claim for a lower amount until after the lawsuit settlement had been approved. And even if it had then agreed to accept as little as a third of the settlement amount after legal fees and costs had been paid, that would have left only about $7,300 for the estate – not enough to cover even the funeral costs, which had been paid years earlier.

By contrast, in a remarkably similar case, after all deductions the MacKenzie estate received $84,700. And according to a settlement document, Mackenzie, unlike Lisa, was totally unaware of what had happened to him. None of the settlement was for his pain and suffering. It all was for the wrongful death.

Also, a legal document filed in the case notes that the total amount was high given MacKenzie’s age and that he had no dependents. “I [the plaintiff’s attorney] recommend the settlement of the wrongful death claim for the sum of $125,000 as it represents in my judgment and experience and under established precedent a very substantial recovery if not a maximum allowable recovery for the death of an 81 year old man who was a widower, retired from the workforce and had multiple underlying and predisposing health risk factors,” it says.

Both Lisa Baker and Alec MacKenzie died before a change in the law that would probably have prevented Samaritan Hospital from receiving the $13,000 and the $74,000 in the first place. In 2008 Medicare stopped paying for treatment resulting from what are called "never events.”

One of these ‘never events’ is “… death or serious injury arising from hypoglycemia, the onset of which occurs while the patient is in the care of a healthcare facility.”

-- David Baker



Lisa in Samaritan Hospital: A day by day account


Joined on the Internet



COMMENT


Zenzen and Leinung: Two
names linked in cyberspace



By David Baker
First posted Sunday, November 8, 2009

In a posting on this page last year, it was predicted that Dr. Matthew Leinung’s astounding claims about Lisa Zenzen’s preventable death in Samaritan Hospital would follow him on the Internet for the rest of his career.

It is already happening: Do a search for “Matthew Leinung” and in the first couple of pages there will be a link to the earlier posting on this page that describes Leinung’s outrageous claim that it is not a deviation from the standard of care for a nurse to ignore a hospital’s printed instructions for treating hypoglycemia – instructions which a doctor had specifically ordered in writing that same day was to be used if Lisa became hypoglycemic.

Then do a search for “Lisa Zenzen.” Again, in the first few pages you will find a link to the same posting about Leinung’s affidavit.

And that is with just one item on Lisa’s page. Soon, the two names will be at or near the top of every search for “Matthew Leinung.”

Like it or not, Dr. Leinung is now inexorably linked in cyberspace to the person whose death he – likely for several thousand dollars – was willing to explain away.

It is significant that in his affidavit there is no mention of his job here at Albany Medical Center as head – since 1996 – of the hospital’s endocrinology division – even though citing that position would presumably have enhanced his credentials in the eyes of a judge. It appears he thought he could remain almost anonymous.

In fact, it took all of five minutes on the Internet to track him down. Further searches soon produced his home address and even the name – from a mortgage document – of the doctor who appears to be his live-in partner


That’s the effect of the Internet: Your past – as well as your present – is always just a mouse-click away. For Matthew Leinung, that's not good. But then maybe he didn't spend all that insurance company money in one place.


Leinung's affidavit: How it was reported here

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E-mail: answersforlisa@hotmail.com

www.twitter.com/answersforlisa

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Sunday, September 06, 2009

Wanted: your story

Have you or someone you know been injured and believes it was caused by a doctor or nurse? If so, I would like to hear about it.

Your identity will never be revealed to anyone without your express permission. The e-mail address is

answersforlisa@hotmail.com

SITE GUIDE 1


A new visitor's guide to this blog




Section 1: The silence of the media

On a Sunday morning in September 2004 – nine months after Lisa died – I was reading the Times Union and noticed that there were a lot of advertisements for Northeast Health. I found four of them that day, three of them in just one section, and all quarter-page announcements. And then it occurred to me that that I couldn’t remember when I had last seen a story about a medical malpractice lawsuit against Northeast Health, or any of the area’s other medical providers.

So I went to the computer and logged on to the TU’s own archives. Twenty minute later, I knew why I couldn’t recall a malpractice story.

There hadn’t been one.

Not for five years. It was as if not one of medical providers who advertised in the Times Union had been sued, even once, since 1998.

But a check of on-line court records showed dozens of such suits, many of them alleging deaths and serious injuries.

So I wrote to TU Editor Rex Smith and then-publisher David P. White, setting out what I had found and asking them for a comment.

There was no response.

Then I posted a column based on the letter.

TU ignores lawsuits

Later in another post I pointed out that the TU wasn’t refusing to print any stories about Capital Region medical malpractice lawsuits; only ones filed against its advertisers.

A tale of two deaths


In August 2009 Hearst Newspapers published the results of its investigation of medical errors. “Dead By Mistake” concluded that as many as 200,000 people – double previous estimates – are dying each year as a result of mistakes.

Other papers in the Hearst chain have run follow-up stories, but the TU has all but ignored the topic; Smith has not said a word about it in any of his columns.

The week “Dead By Mistake” appeared I posted an open letter to Smith, and sent it to him and publisher George Hearst III, asking for a commitment to follow up on “Dead By Mistake” by reporting at least some of the malpractice lawsuits filed against Capital Region providers.

Again, there was no response. And still the TU maintains its silence on local medical errors.

Smith open letter


The Cedeno tragedy

There was a time when the area’s media didn’t suppress local medical malpractice stories. In 1985, two doctors at Albany Medical Center Hospital made a terrible mistake that took the life of two people, a pregnant woman and her child. The case made news not just here but across the country. Here's how the story was recalled here:


Med error kills mother and child


Site guide 2


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SITE GUIDE 2


Section 2


Steve Coffey

In 2006, an attorney who in 2005 had filed a lawsuit against Samaritan Hospital all but abandoned the case without telling me. As I searched for another attorney, I received a call from Stephen Coffey of O’Connell, & Aronowitz. This was a surprise because a few months earlier another partner in the same firm, citing a full case load, had declined to look at my case.

Now Coffey was saying that he would review my file with a view to taking over the case. But what he didn’t tell me was that his firm was already representing an organization that had as a member, Samaritan Hospital.

What happened next can only be seen by any reasonable person as a deliberate attempt over several weeks to get my case thrown out of court. Those events were described a series of posts on this page.


Coffey rejects case


Lawyers’ committee complaint


Coffey's revealing admission

The Committee on Professional Standards ruled, without any explanation, that Coffey’s actions were not misconduct and closed its filed. But after a detailed letter to a judge on the Appellate Division – of which the committee is a part – the committee agreed to “reconsider” my complaint. But several months later, again, with no explanation , it once again said it found no ethical breach.

That was before the committee knew that during a visit to the committee’s offices I had secretly recorded an extremely revealing 25-minute conversation with one of the committee’s investigators. A transcript of that encounter will be made public at a later date.

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Samaritan Hospital may be accused of killing patients but that doesn't stop it from asking them for a donation - THREE times.

Just send us money

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Saturday, September 05, 2009

It happened again


Hospital settles lawsuit

over death of diabetic

By David Baker
September 7, 2009

A lawsuit in which Samaritan Hospital in Troy was accused of causing the death of an 81-year-old man with diabetes by failing to monitor his blood sugar levels was settled in 2007 for $125,000.

The lawsuit was brought by the family of R. Alec MacKenzie of Washington County.

According to the suit, MacKenzie had been transferred from a nursing home to Samaritan Hospital in June of 2004 for management of his diabetes and specifically his glucose levels, and his condition, which required insulin and close monitoring, was known to the hospital.

“On a previous admission to the hospital he had experienced mismanagement of his diabetes and physicians orders and hospital protocol was implemented for him relating to his glucose assessment and management and were in place at the time of his June, 2004 admission,” a document filed in the case says. “Unfortunately, the hospital staff failed to consider the physician’s orders previously written for him or the protocols established and as a consequence he was not property monitored in conjunction with his insulin glucose and nutritional management. His blood sugar levels were not timely measured and determined at safe intervals.”

According to legal papers, at 10:42 on the evening of June 25, 2004, MacKenzie’s blood sugar was found to be at 99 milligrams per deciliter of blood. This, the suit says, was a significant drop from a reading taken six hours earlier.

“However, in the face of that reduction there was no further blood sugar testing done until June 26 at 6:27 in the morning at which time Mr. MacKenzie was found to be comatose and unresponsive,” the document says. “The blood sugar reading at that time was 48 and when repeated was found to be 38.”

The suit says MacKenzie never regained consciousness and died seven days later.

A search of local newspaper archives produced no indication that the case was reported.

The lawsuit was filed in October 2005 on behalf of MacKenzie’s relatives by Troy attorney E. Stewart Jones. It was settled in August 2007.

The hospital was represented by Scott Johnson of the Albany law firm Thuillez, Ford, Gold, Johnson and Butler.
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