Two nurses lose sister, find their faith in medical profession shaken

Two nurses lose sister, find their faith in medical profession shaken

By Tracy Weber, Los Angeles Times Staff Writer
September 9, 2007

For 50 years Linda Sue Brown's nine siblings fiercely protected her, facing down anyone who would taunt her or seek to exploit the disability that left her with the mental capacity of a 12-year-old.

That sense of responsibility only grew after their 81-year-old mother, Brown's lifelong caretaker, was stricken with Alzheimer's disease, leaving her unable to tend to her daughter.

So when Brown's lower legs swelled last summer and she grew short of breath, her eldest sister rushed her to a place the family knew and trusted: Brotman Medical Center in Culver City. One of Brown's sisters, Thelma Allen, worked there as a nurse; another, Rosslyn Diamond, had previously been a nurse there. And Brown had been treated there, successfully, for years.

At the 420-bed hospital, tests revealed that Brown had an enlarged heart, fluid in her lungs and severe anemia, medical records show. She received blood transfusions and, two days later, an emergency hysterectomy. Afterward, Allen was given an unorthodox, but welcome, assignment: She was to be one of Brown's nurses.

On July 4, after her shift ended, Allen watched TV with Brown, then kissed her good night.

By the time she returned the next morning, her sister was dead.

more...

http://www.latimes.com/news/printedition/front/la-me-brotman9sep09,1,3615198.story?ctrack=6&cset=true

her death? I don't want to register at the LA Times to read the article.

Thanks! :hi:

After months of investigation, state health inspectors determined that Brown's death was nothing so random as an embolism.

Brotman staffers, the inspectors found, had failed Brown in virtually every way: Her nurses -- Allen's colleagues -- appear to have forged consent forms and had Brown sign agreements that she couldn't understand. One failed to call for help as Brown's vital signs plummeted.

Her doctors didn't investigate signs of heart failure, performed a risky emergency surgery with no clear justification and then didn't intervene as her condition deteriorated. And hospital officials didn't even look into what went wrong until inspectors inquired.

"That is just a pretty phenomenal failure," said Dr. Eric J. Thomas, an associate professor of medicine at the University of Texas, Houston, and a patient safety expert who reviewed Brown's medical records and the state report for the Los Angeles Times.

"Certainly anyone would classify it as a preventable death," he said.

lots more...

The sisters thought that because they worked for the hospital they would be able to get to the bottom of their sister's death. But the hospital circled the wagons and prevented them from getting answers.

What a horrible story.

Sites are weird like that. Thanks for the extra info.

The link requires a login, which I don't have.

The health department report faulted nearly all of Brown's caregivers, beginning soon after Brown arrived in the emergency room.

The report said doctors failed to investigate Brown's enlarged heart and the fluid in her lungs as signs of congestive heart failure.

Transfusions ordered by Houston, who was not in the ER and was in contact by telephone, forced even more fluid into her lungs, the report said.

The coroner later found that an enlarged heart muscle, unable to pump effectively and stressed by an abnormal heart rhythm, led to Brown's death.

Inspectors found that Houston, who did not examine Brown until 11 1/2 hours after her arrival in the ER, had "no current core privileges to practice in the facility," the report said.

Later, gynecologist Salceda performed an emergency hysterectomy with no evidence that Brown was "suffering from acute, life-threatening vaginal bleeding at any time" before her surgery, inspectors said.

The only reports of bleeding, inspectors said, came from Brown, who was described in medical records as a "poor historian poor cognition."

Dr. Luis Torres-Garcia, the anesthesiologist who raised concerns, was "unable to explain" to inspectors why he ultimately agreed to go ahead with the surgery.

Houston and Torres-Garcia declined to comment. Salceda did not return calls for comment.

Finally, the inspectors said, as Brown's condition worsened on the night of July 4, no doctors examined her.

Even as her vital signs plummeted in her final three hours, there was no evidence that her nurse alerted her superior or any physician, according to the report.

The nursing staff was cited for its repeated failure "to act as the patient's advocate."

"Someone should be in handcuffs."

They later discovered that Linda Brown had signed the consent herself, even though her mental limitations required an authorized surrogate to sign on her behalf, according to health inspectors. On other hospital consent forms, her signature appeared falsified, the inspectors found.

If mistakes were made, said Brotman's chief executive, Howard H. Levine, "you have to realize that in a hospital, any time you have the human element involved in care, there's going to be an error or two, unfortunately."

"If" mistakes were made, then what kind of "error" causes forged documents?

Oops - K&R!!! :)

to make her medical decisions. The HCP would have taken strident measures to find out the rationale behind each surgery and treatment, thus thwarting the potential for death.

a power of attorney to make health care decisions for her. Since they were both nurses, you'd think they'd have made sure to do this rather than allow her to sign things when she didn't fully comprehend what she was signing. I guess they thought they'd be keeping an eye on things in person.

The only emergency hysterectomies I've ever heard of occurred when a woman's uterus ruptured during childbirth. Both cases involved four or five pregnancies in four or five years, though obviously other women have many more children, and spaced that closely, too, without having a ruptured uterus.

Women suffering from excessive bleeding and pain caused by endometriosis don't have emergency hysterectomies, as far as I know. In fact, many hospitals require a laparascopic diagnosis before scheduling surgery. The surgeon has to have a look around with the scope and see what's going on.

I'm not sure they do emergency hysterectomies on women with uterine cancer, either. They'd do it soon, of course.

This is an odd case.

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Enjoy your brief stay.

capable of taking of herself.

I'm not sure what you are trying to say here--sounds like "your sister is better off dead." If I'm wrong on that, sorry, and what *are* you trying to say? If I'm right, sounds like a long-distance diagnosis like Frist's....

http://www.bugmenot.com/view/www.latimes.com

Enjoy.

It's curious to juxtapose this sad tale with the Katrina nursing home incident.

http://www.medicalaw.net/july_1,_2002_legal.htm

Fraud and Abuse

US v Tenet Healthcare
Settlement

Tenet has settled the suit by the government over its national laboratory and billings at two of it's hospitals. it agreed to pay $55.75 million for fraudulent cost reports in it's Florida Palmetto Hospital home health agency and the California Brotman Medical Center. This was a whistleblower suit by the former Brotman Controller, who will get about $2 million.
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And what is with allowing the sister be one of the woman's nurses?? At my former facility if a staff member's family member is admitted, they don't even allow the patient to be put on the staff member's floor never mind have family be the nurse!! If the patient absolutely has to go on the nurse/family member's floor, then the nurse is floated to another floor.
And at what point was the sister assigned as the nurse? How close to the death? If she was the nurse, she had access to the chart and information that would have possibly given clues to the patient's deterioriating health..did she call anyone?
I feel for the family but as a nurse myself who had a family member in the hospital recently, I was all over the staff right when poor care was being given or when there was a change in condition. Were they happy with me, hell no, someone even put a banana in my sister's car tailpipe (rural hospital, empty parking lot, my relative was literally the only patient in the brand new hospital so the likely culprit was the staff who glared at us whenever we arrived at the hospital).