Medical Error Takes a Life: A Daughter’s Plea for Answers

Annette Smith’s father died of a medical error & almost 2 years later she still doesn’t know exactly what happened to him


My 65 year old father, Curtis James Bentley, died in a hospital, and yet almost two years after his death, I still do not know what happened to him. The hospital and my father’s physicians have not provided this information. Why?

My father had recently undergone successful surgery to place a stent in his heart at Emory Healthcare. The procedure had gone well. I was told that he was “100% clear,” and he was discharged from the hospital and went home. However, a review of his discharge summary recently revealed he was sent home with eight abnormal blood levels. This was a beginning of his demise in my opinion.

While recuperating at home, he started bleeding. He was coughing up blood, having nose bleeds and blood was present in his stool and in the toilet.

I took him to the ER at Piedmont Henry Hospital, where he was diagnosed with a lesion in his colon and admitted to ICU. That was Friday, September 7, 2012. I left once on Saturday to get food and clothes in preparation for staying with him the entire weekend if need be. We were supposed to go fishing.

 

A failure to check?

However, on Sunday morning, I woke up from dozing on and off. No one had been in my father’s room for the past two hours since 2 am. A nurse finally came into my father’s room around 4 am. It was very brief. After not checking him for two hours, you would think it would be more thorough. I took the opportunity to take a much needed break from my vigilance at my father’s bedside.

I went to the restroom, stopped at the snack machine, called my husband and sat for awhile in the waiting room. While I was away from my father’s room, I heard a Code Blue sound. At first I thought it was for him, but it was for the neighboring patient. I sat a little while longer, but then I had an uneasy feeling. Something told me to go check on him.

I went back and saw that the Code Blue was indeed for the neighboring patient and that many physicians and nurses had responded. However, no one was with my father.

28 COMMENTS

    • Dianna Colbert, I’m so sorry for your loss. I also apologize for just seeing this message. What a sad story. Since becoming an advocate, I too have found that I am not alone. Perhaps one day all of our voices will be heard and change will come.

  1. I will say that I had a similar experience of not so benign negligence with my own father when he had a stroke. He needed perfusion CT scanning, which wasn’t available at the hospital he was initially taken. The hospital called to arrange transfer to a facility that did, and it was about a 15 minute drive away. Unfortunately, the transport did not show up to pick him up to take him until THREE HOURS later. By the time he got to the other facility, the clot had miraculously resolved itself. However, if it had not, it would have been entirely too late for us to use thrombolytics to treat him. When I later called the hospital to find out what happened, I made it clear that it was solely by the grace of God they were talking to me and not to my attorney. They admitted to me their error, but I couldn’t help but wonder whether that was only because I am a physician. if my brother had been the one to make the call, would they have admitted the mistake?
    Oh, the reason it was 3 hours late is because they insisted on using the transport company owned by the company who owned the hospital (instead of the first available ambulance transport).
    I am so sorry for your loss, Annette, and I hope that you get answers. As physicians we’re told never to admit when we’re wrong, but the longer that culture continues in health care, the more unnecessary mistakes are made. Unfortunately, in many cases we aren’t always sure why a patient deteriorates, but a good physician will review a patient’s experience with him or with his family and explain what we can. Patients generally understand that doctors and nurses aren’t miracle workers and that sometimes you just cannot prevent a bad outcome. But patients deserve to know that their providers care for them genuinely, and the only way to share that genuine care and concern is through good communication.

    • Coming from a physician means a lot. Failure to monitor needs global attention. There were some errors made such as low labs, not addressing critical issues that could possibly have prevented his death. Those errors reduced his chance of surviving. His issues weren’t addressed in time. The failed to realize he was deteriorating. I guess “practitioners” means was it says…doctors PRACTICING medicine…The only way to minimize these types of errors is as you said to have “GOOD” physicians review a patients or caregiver for that matter, experience and do some explaining. Those physicians are rare… Thanks again for your input.

  2. m so sorry for your loss. I completely disagree @Arosswoods & think you were a tad insensitive & presumptuous to offer your opinion of misplaced grief. That isn’t in there & frankly unkind to suggest even if you thought such. Annette, I can’t possibly know all factors in your case from your narrative but I see some red flags not just with the nurse matter but the diagnosis of a colon lesion after a heart stent. I am willing to help you. Please find me on twitter, we can follow, DM then email from there. Im an expert in psychology in medicine (for practitioners & patients) and I use that to analyze the way medical decisions are made & perceptions are formed. Obviously very familiar with general medicine. I can be fair & look at all sides, but can definitely do a fairly evolved job of assessing if errors were made, where & perhaps guide you as to what steps you might consider depending what your ultimate goal is. If accurate, it is devastating to imagine that your father was in a coma & brain dead and you as a primary family member wasn’t notified. I really would need some more information. Again, so very sorry for your loss and for all these lingering questions.

    • Thank you so much for your thoughts and coming to my defense. It’s comforting to know someone cares and is actually reading my story, as well as be willing to help! I had to read his medical records and glean for myself what actually happened to him. They would offer hope, yet not telling me he was in a coma. I asked them several days ago, if they do an “investigation of all it’s Blue alerts to find out what was going on with the patient for 12-18 hours before the code to see if anything could have been done to potentially avoid the alert; everyone benefits from reflecting on and learning from an event.” They have yet to respond. That was 8 days ago. I ask that PPAHS do an article on “The Life of Patients 12-18 hours Before a Code; What Can Go Wrong and What to Look Out For.”

  3. Cant believe the rude comments. So many times nurses not doing hob, then use phrase, calm down , so can lie someone not stable. Good nurses never act like this. Her right to know and justice, is not misp lo aced; some comments here are, as is the hospital and staff who did this and lack of accountability. Do yiur jobs, as being paid more than the masses as minimum wage, and respect customer service, fact its people right to quality and their life. Medical should respect life.

    • “Assumptions” While some may get a phone call in the night, I was there! I SAW it all. I may not have a medical degree, but it doesn’t take a degree to know what the care should be for individuals on ICU. INTENSIVE CARE! Intensive care units cater to patients with the most severe and life-threatening illnesses and injuries, which require constant, close invasive monitoring and support from specialist equipment and medication in order to ensure normal bodily functions. Notice, “close invasive monitoring.” The equipment didn’t alert them nor was the staff where they should be. You assume when you weren’t there and don’t know and have to take their word for it. Again, I WAS THERE! I’m not blind…

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