More from the archives
State officials let hospitals
hide deadly medical errors
Ahead of an imminent campaign to bring this blog and its sister web page to the attention of a new and much larger audience, selected older posts are being rerun. Below is the second in a series of items that have appeared here since the blog was launched in 2004, the republication of which may assist new visitors to these sites. This one is from 2009.
By David Baker
First posted Tuesday, August 25, 2009
Re-posted Wednesday Oct. 24, 2012
In a story about a mid-air collision last month between a helicopter and a light plane in New York City, the Associated Press has revealed some details of the investigation into the cause of the crash. The AP obtained a copy of a transcript of a telephone conversation between an air traffic controller at Newark International Airport and a friend that took place just after the controller had cleared the light plane to take off and had handed control of it to a controller at another airport.
It appears that the Newark controller’s private conversation – during which he joked about “barbecuing a dead cat” – violated agency rules but did not play any part in the collision moments later in which nine people were killed.
The point though is that these details are already public, and that even if the AP had not obtained this transcript, the National Transportation Safety Board will carry out a detailed investigation and then write a report, which may identify the cause and will probably include recommendations investigators believe will make a similar accident less likely.
And that report will be made public.
Compare that with how the state Health Department handles the findings of its investigations of deaths and serious injuries in New York hospitals.
In most cases they are kept secret, not only from family members who have been appointed as legal representatives of an estate but even from elected state officials.
That’s what happened in Lisa Baker’s case. While a patient in Samaritan Hospital in Troy in 2003, Lisa lapsed into a coma after her glucose level – according to the hospital’s own records – had dropped to an almost non-existent 2 milligrams per deciliter of blood. This happened less than six hours after she had become hypoglycemic, during which, I found out later, nurses failed to follow the directions in the hospital’s own printed instructions for treating low blood sugar and, in doing so, ignored a doctor’s specific written order in Lisa’s chart to follow those printed instructions.
Then, after I learned from another doctor that records from that night had been removed from her chart, I made a request to the state Health Department for an investigation.
Six months later, Karen Rant, a ‘hospital nursing services consultant’ at the department’s office in Troy, called to tell me that an outside organization had decided that the care given to Lisa that night was appropriate and as a result, no action would be taken.
Rant said department staff were stunned by the decision, and she certainly sounded shocked. During the months following Lisa’s collapse and death I had had numerous conversations with her and she had told me it seemed likely that the hospital’s staff had allowed a preventable injury to occur, by not following the hospital’s written protocol after the first episode of hypoglycemia, and possibly also by mistakenly giving Lisa quick-acting regular insulin instead of Lantus, which is released into the blood evenly over 24 hours.
Rant also told me that the report said some key documents were missing from Lisa’s medical records.
But the writer of a very brief “Summary of Professional Analysis of Care” I later obtained from the department dismissed any suggestion of improper care. The reviewer says the care was ‘appropriate’ and he or she twice insists that Lisa “… was being monitored closely”, even though the hospital’s records show that her blood glucose level was checked only once after the first hypoglycemia episode, and that that was four hours before she was found almost dead and with a glucose reading of 2 mg/dL.
The reviewer says nothing about the nurses’ failure to obey a doctor’s direct written order, or their failure – again, documented in the hospital’s own records – to follow specific instructions in the hospital’s hypoglycemia protocol that the doctor had said in that written order was to be used if Lisa became hypoglycemic.
This ‘analysis’ was done by an organization called IPRO – which is partly funded by health care providers. The person who wrote it is almost anonymous, being identified only by a number: 350257. There is no indication that anyone at IPRO interviewed any of the people at the hospital who were on duty that night, which, Karen Rant had told me, staff from the Health Department's Troy office had done 13 days after Lisa's collapse.
So, after seeing this summary, I asked the department for a copy of the full report.
They wouldn’t give it to me.
I filed a request for it under the state’s Freedom of Information law.
It was ignored.
I filed an appeal with the department’s main office in Albany.
It was denied.
So I wrote to then-Health Commissioner Antonia Novello.
In response, I received a letter from a Ruth Leslie of the Bureau of Hospital and Primary Care Services in Troy. In the letter, Leslie said that the department’s function in this case was to find out if there had been any violations of “the codes, rules and regulations of the State of New York.” and that because of the “medical complexity” of Lisa’s case, the regional office had sent the chart to IPRO for “an independent determination of whether the standard of care had been met.” This review, Leslie wrote, was in addition to, not in place of the department’s own assessment that all the rules and procedures had been followed by the hospital in its care of Lisa.
That, of course, was not what Karen Rant, in the same building, had told me the staff in Troy had concluded about Samaritan’s care.
But if the care documented in the hospital’s own records really was acceptable under the state’s rules, it seemed that those rules needed to be changed.
So I wrote to Richard Gottfried, who was then and still is chairman of the state Assembly’s Health Committee, and to Kemp Hannon, chairman of the Senate Health Committee. I asked both of them if their committees would examine the circumstances surrounding Lisa’s death and determine, among other things, if ignoring a doctor’s direct order was allowed under the state’s rules and procedures, and if so, whether the chairmen thought that perhaps the rules should be changed.
It took several months to get any response from either of them. Hannon’s staff told me each time I called that someone would get back to me, but no one did. Then, when I pointed out to a staff member that she had been saying that for almost a year, Hannon told New York Post columnist]Fred Dicker – who had mentioned my attempts to get Hannon’s attention on his Albany radio show – that I had been rude to his staff. Dicker evidently believed it and dropped the matter.
I never did hear from Hannon, which might be because as Senate Health Committee chairman he had received almost a million dollars in campaign contributions, most of it from health care interests and some of it directly from Northeast Health Inc., the company that operates Samaritan Hospital.
Gottfried, who also had being mentioned by Dicker, did eventually try to help. He wrote to Novello, asking for a copy of the IPRO report.
Novello refused to give it to him and Gottfried, while acknowledging that I might not find it satisfactory, told me he would take it no further.
Then, at Dicker’s suggestion and in a final attempt to get the report, I contacted then-Senate Majority Leader Joseph Bruno’s office. During several conversations, Karen Crummy, an attorney on his staff, said she thought I ought be able to get a copy of the report and that she would contact the Health Department on my behalf.
Four months later my call to her was returned by a spokesman for the senator, who in an unfriendly tone told me that I was not going to get the report, or even hear any more about it from the senator’s office. And I never did.
It seems almost certain, given what I was told by the Health Department’s Karen Rant, and that no one will let me see it, that the IPRO report did in fact identify mistakes made by those nurses. If so, it probably would also have contained detailed recommendations for preventing the same thing happening again – even as the hospital, through its lawyers, denied any responsibility for Lisa’s death, flatly denied that key medical records ever existed and for four years did everything possible to avoid being held accountable.
And why wouldn’t they? Everyone, it seems, has been putting a lot of effort – and money – into to keeping preventable deaths and injuries from public view. The providers, the politicians and, most disturbingly, the media, have all joined to hide the terrible truth. Meanwhile, we now learn that the number of avoidable deaths and injuries are not only much higher than had been acknowledged, but are increasing at an alarming rate.
Clearly, this secrecy, while benefiting those involved, has not encouraged providers to reduce errors. In fact, it probably has had the opposite effect, since providers are shielded from the enormous damage that would be done to them by bad publicly.
But it threatens the life of every resident of the state. They deserve to know the truth. That’s why I am working on a Web site that will make hundreds of past and pending claims made against Capital Region providers visible for all to see.
As visible as that collision last month in the sky over the Hudson River in New York City.