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

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When I walked in, I couldn’t see my father’s face right away. One leg was hanging out the bed. Embarrassed, I asked him what was he doing, but he did not respond. I asked him a second time as I was covering him up. The TV went to a commercial at that moment and the light hit his face which was down against the railing. He was positioned like he was trying to get out, perhaps trying to get help.  When I looked closer, I saw that my father was taking his last breath. I knew immediately that it was his last breath, as my step father had died in my arms. Their last breaths were identical.

I ran out calling for help.

A nurse came. During this time I’m yelling, “Where were you, where were you?” One nurse had the nerve to tell me, “You need to calm down!”  I told her, “Don’t tell me to calm down! Where were you? Why wasn’t a code called for him?” She had no answer.

I had been in the room with my dad. No nurse had been present. No machine had alerted them to his deteriorating condition. Someone should have seen him, visually, as recommended by the Institute for Safe Medication Practices.

My father was intubated and placed on life support.  I found out by reading his medical records that he had gone into a coma, was brain dead, suffered paralysis and necrosis. No one at the hospital told me that. He was in a coma for seven days and he never came out of it. Research shows, those types of adverse events are sustained from going too long without oxygen. What happened to Curtis James Bentley from 4-4:45? Was he calling for me? This was a critical moment that was not documented and haunts me.

A day or so after the code, I talked to the charge/manager nurse about what her staff had done (or rather not done) on that awful morning. She brought one of her fellow nurses in as a witness, I guess. My sister was there, too. I explained to her that there was no one around when my dad coded. No one was at the station monitoring him, nor any of the other patients for that matter – all except for the neighboring patient for whom the Code Blue had been called.

 

Our focus is on one patient

The charge/manager nurse told me “Well, when our adrenaline gets going, our focus is on one patient.”

I took a deep breath. The tears started rolling. I asked her, “You mean to tell me, if you have 15 patients on ICU, they are going to go uncared for because your focus is on one patient!?” She couldn’t say a word. She knew that was the wrong thing to say. She had just admitted that they had neglected to treat my father, while attending to that one neighboring patient.

I told her she shouldn’t say that to people. Then she said, “I’m sorry; someone is supposed to be monitoring these patients at all times.”  I expressed my guilt for leaving his side and she fed me this story about leaving her mother home alone. She died too. It brought no comfort to me. Not after what she had previously said.

During those next seven days, I talked to my father, because I was told the hearing is the last to go. I called to him. I begged him not to go. I finally said enough is enough.  It took everything in me to sign the form to take him off life support. My oldest sister and I lay on his chest until … My baby sister and my best friend were there giving us much needed support. I had to endure those last breaths…one-last-time…

This nurse and her colleagues had dropped the ball. But, tragically, this was not a game – my father lost his life, because they dropped the ball.

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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