It happened again
Ten years ago this week and after 21 days in a coma, Lisa Baker died in the hospital where she had been found in her hospital bed with a blood glucose level near zero. Medical records showed that nursing staff had not followed the hospital's own protocol following a mild hypoglycemic episode a few hours earlier.
Seven months later, a second patient with diabetes died in Samaritan Hospital in Troy NY. As was reported on this page in 2007, the lawsuit filed in that case made allegations that were almost identical to those made in Lisa's case.
Here is the story about the second case, followed by an editorial about a hospital management that appeared to have learned nothing from Lisa's death.
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.
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 sieven 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 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 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.