12 questionable deaths - 16 settled malpractice cases

[thedrifter]

12 questionable deaths - 16 settled malpractice cases

They happened at Florida's Jacksonville Naval Hospital. All because of Bad medicine

By William H. McMichael
Times staff writer

JACKSONVILLE, Fla. - Navy wife Dona Perez was surprised when a Jacksonville Naval Hospital doctor told the 38-year-old in April 1999 that she needed a total hysterectomy and should have her ovaries removed. Suffering from irregular menstrual periods, vaginal bleeding and heavy pelvic pain, however, Perez agreed to the surgery.

But during the July 1, 1999, operation, her gynecologist, Lt. Cmdr. Margaret Larkins-Pettigrew, accidentally cut Perez's bladder. Then, trying to repair the nick, Larkins-Pettigrew made matters worse still, inadvertently sewing shut the tube that runs from the kidney to the bladder. Unable to drain, the kidney died.

However, it took a year of tests and repeated visits to the hospital before Dona learned the cause of her pain and urinary problems. Dona's husband, retired Radioman 1st Class Jose Perez, was livid as he sat with Dona in the office of a urologist, Lt. Cmdr. Stacy McBroom, the following October.

"How could this happen?" he demanded. Said Dona, "And she sits right there and states to us, 'It happened during the hysterectomy.'"

The tube inserted to drain the bloated kidney caused an infection, and the organ had to be removed. That operation, in January 2001, nearly killed her. McBroom sliced the large vein that carries blood back to the heart. Blood gushed everywhere, and Perez had a heart attack on the operating table. She woke up four days later in the hospital's intensive care unit.

Dona, now 45, says her continued problems with incontinence have made her a recluse. She's undergone dialysis and fears losing her remaining kidney.

"I cannot travel anymore like I used to," she said. "We used to do a lot of things with our children. Traveling two hours is about as far as I can go."

The Perez family settled with the government for an undisclosed amount.

The near-death of Dona Perez is just one of at least 16 cases litigated since 2000 in which malpractice by doctors assigned or contracted to Jacksonville Naval Hospital left patients disabled, crippled or dead, as documented in federal court papers and interviews.

Another two Jacksonville malpractice cases are in litigation. (In one recent judgment, involving the death of an Army veteran, the judge ruled in the hospital's favor.) And a Jacksonville law firm that has handled eight of the 16 cases says there are more to come: The firm recently took on four more alleged malpractice cases from 2005 and is considering four others, also from 2005.

In the 16 completed cases, 12 patients died. They died for reasons ranging from failure to diagnose obstetrical problems to deadly infections that set in after surgical errors. The nonfatal cases were even more costly to taxpayers. In late 2005, federal judges awarded two families a total of $67 million for procedures that left one child blind and another brain-dead.

All told, the malpractice lawsuits at Jacksonville are rife with detailed allegations of medical mistakes. They include failure to read charts before surgery; misdiagnosis combined with neglect of other avenues to a correct diagnosis; and out-and-out surgical blunders, such as the two suffered by Dona Perez.

Mistakes happen at all hospitals. Malpractice suits often follow. While the number of lawsuits at Jacksonville Naval Hospital, which has only 60 beds, appears high, there is no standard way to compare that rate to other military and civilian hospitals. The comparison to civilian hospitals is especially difficult because the military patients at Jacksonville are barred by law from suing.

But one measure of the problems at Jacksonville is this: The Navy says it cannot provide a total count of malpractice suits against the hospital because the information is not centrally tabulated.

Even though the Navy says it can't tell if the rate of malpractice at Jacksonville is unusually high, it thought the hospital had enough problems that it sent a hand-picked commanding officer to straighten things up.

Capt. Raquel Bono, who took command of the hospital in mid-August, has held a string of high-profile jobs in the Navy medical community. In her previous job, she was executive assistant to Navy surgeon general Vice Adm. Donald Arthur, responsible for helping him police high standards of care in Navy medicine.

All three officers who commanded Jacksonville in the six years prior to Bono's arrival - Capts. Barbara Vernoski, Ralph Lockhart and, most recently, John Sentell - are retired. Vernoski, the only one who could be reached for comment, declined to do so. All left under normal circumstances following a standard two-year tour, Navy officials said.

In her six months on the job, Bono has already launched a new strategic plan to get the hospital on track. She's held a town hall meeting at the hospital and is meeting with individual military units and veterans' groups in the area.

Bono also expressed regret over the blunders in a Jan. 13 interview, the first time any Navy official had publicly done so.

"The primary thing is really acknowledging that this is a source of tremendous pain for a lot of our patients when an adverse outcome occurs," Bono said. "And we regret that. We regret the pain that it's brought to them, and the loss and the suffering that the patients and family members have experienced because of this."

At the same time, she called the malpractice cases "isolated" and said that they did not indicate systemic issues. "I have reviewed all of them," she said. "I've not seen any discernible trends."

Arthur agreed, saying he'd also reviewed the cases and that he saw no commonalities among them.

Not 'isolated incidents'?

But local attorney Sean Cronin disagrees.

"I do not believe they are isolated incidents," said Cronin, who is a P-3 pilot in the Navy Reserve and has represented many of the families in past and pending cases. "I think there are systemic problems at the hospital, as indicated through the cases that I've reviewed."

Cronin says one link between the cases is a lack of continuity of care - that is, patients being handed off from doctor to doctor for the same problem.

Over a four-day span during the first week of February 2004, nine different Jacksonville caregivers saw or provided advice over the phone about the care of 8-month-old Michael Hugaboom.

Their diagnoses ranged from a viral upper respiratory infection to bronchitis to chicken pox.

Within a week of first being seen, Michael Hugaboom was dead from severe sepsis, an overwhelming bacterial infection of the bloodstream, and meningitis.

His parents, Aviation Support Equipment Technician 2nd Class Thomas Hugaboom and his wife, Jessica, are suing the government for the wrongful death of their son, seeking $15 million in damages.

They announced the filing Dec. 7, 2005, shortly after a federal judge in Miami ruled Nov. 23 in favor of a Navy family in a case involving negligence after the birth of their son.

In that case, the judge awarded $60.9 million - believed to be the largest judgment ever awarded in a Federal Tort Claims Act case - to Machinist's Mate 2nd Class Oscar Rodriguez and his wife Raiza Bravo, ruling that negligence at Jacksonville Naval Hospital during the 2003 birth of their son Kevin, now 2, left him blind, deaf and mute, with the mental capacity of a 1-month-old.

Bravo had been in labor for more than 12 hours and her baby's heart rate was slowing. At 7:30 a.m., a new obstetrical team took over and, despite increasingly negative fetal test results, continued pressing for a vaginal birth.

The child's heart eventually stopped, and the boy was delivered by emergency cesarean section at 1:35 p.m.

The doctor who led that team, civilian resident physician Kenneth Kushner, admitted at trial that both he and the doctors who managed the shift before him failed to meet the standard of care by failing to call for a C-section birth by at least 7:30 a.m.; he and two experts agreed that if Kevin had been born by 8 a.m., he would have been normal, court records show.

"I think continuity of care is directly related to many of these cases," Cronin said.

Bono acknowledged that continuity of care is a "challenge across the board," saying it's "one of the things we're trying, something we want to enhance."

She said she hopes to do so by pursuing several initiatives.

One is broadening the reach of what she called the hospital's "multidisciplinary" approach, which aims to employ a range of physicians who can each bring their particular expertise to bear on a given problem.

Another is initiating medical team training to improve continuity of care when a member of the team is deployed or otherwise unavailable.

Finally, Bono looks forward to the creation of electronic medical records - a worldwide Defense Department initiative launched in late 2005 and expected to be fully deployed by the end of this year - that can be easily shared by physicians.

Records bypassed

Jocelyn Foster might still be alive if her records had been properly transferred and read.

Lt. Cmdr. (Dr.) Cynthia Wilkes admitted during a deposition that she hadn't read Foster's records before recommending a hysterectomy because the outpatient records department had not sent them over.

Wilkes also admitted not following up to ask for the records, which indicated previous abdominal surgeries and the likely presence of scar tissue, which can complicate additional surgery. Instead, when Wilkes cut into scar tissue, she accidentally sliced Foster's small intestine. The wound wasn't properly repaired, an infection set in and Foster, the wife of ex-Navy Chief Storekeeper William Foster, died on March 1, 2002.

Bono characterized that and other malpractice cases as having "happened in the past." She said that health care is a "huge-risk field." And she said she is working hard to overcome the problems at Jacksonville.

"I want [patients] to know that we are doing everything we can to eliminate any kind of errors that result in an adverse outcome," Bono said. "It's our duty. We're honor-bound to give them the very best health care possible. And we tirelessly work at that."

Cronin disputed the contention that the Jacksonville malpractice problems are all in the past. He said there are at least two cases against the hospital that are still in litigation, and he has accepted or is reviewing another eight cases, all stemming from procedures that took place in 2005, for possible legal action.

But Sen. Bill Nelson, D-Fla., and a member of the Senate Armed Services Committee, said he is satisfied the Navy is on top of the problems at the hospital. Nelson summoned Bono and a representative from the Navy Bureau of Medicine and Surgery to his office in early December, and he dispatched two staffers to the hospital Jan. 9 at Bono's invitation.

After reviewing his staffers' report and meeting with Arthur on Jan. 31, Nelson said. "I think the problems are being solved."

'They always mention Mom'

Wanda Lloyd got an early start Dec. 21, 2002, and with good reason: It was her 3-year-old twin girls' birthday, and she needed a few more favors for the 9:30 a.m. party. She left for the local Wal-Mart at 7:30 a.m.

A short while later, her husband, just-retired Chief Master Sgt. Terry Lloyd, received a call from an emergency medical team: Wanda was suffering severe chest pains and was being taken to Jacksonville Naval Hospital.

According to court records, Lt. Cmdr. Tatia Grant-Levy, the emergency room doctor, wanted to rule out any threats to Wanda's life, get her stabilized and arrange for proper follow-up care. Grant-Levy listed three possible diagnoses in her Jan. 28, 2005, deposition: a heart attack; a pulmonary embolism, typically a blood clot in a lung artery; or an aortic dissection, or separation of the layers of the aortic wall.

She described Wanda as "crying and hurting," with numbness in her left arm. She asked Wanda about her medical history and ordered up an electrocardiogram or EKG, a test that measures the electrical activity of the heartbeat, and a portable chest X-ray.

She did not order a CT scan.

Wanda stayed in the hospital overnight but died the next morning. The cause of death: aortic dissection, which might have been identified with a CT scan but did not show up on the portable chest X-ray because that process does not yield a full view of the aorta.

"I still get choked up whenever I talk about it," Lloyd said, three years after losing his wife. "Not only was she supportive to me, she was such a loving mother."

The girls, now 6, are growing up motherless. "When they say their prayers and their graces, they always mention Mom," Lloyd said. "So you had such a beautiful person have to leave the world, for negligence.

"I still go out to that cemetery every day," Lloyd said. "It's hard to tear myself away."

The government ultimately settled its case with Lloyd for $1.5 million.

'There was no soul'

More than five years after Anthony Graziani died in his mother Tana's womb, the death continues to haunt the family.

"I'm 9," said Brittany Graziani, brightly, wrapping her arm around her little sister before telling a visitor her age. She nods at her sister Madison. "She's 4. And my brother's 5."

The infant, more than 33 weeks along, was suffering from intrauterine growth retardation, meaning he was smaller than he should have been at that point. According to a 1998 study in American Family Physician, fetuses with IUGR should be closely monitored, with delivery before 38 weeks of gestation "usually recommended" because most fetal deaths involving IUGR occur after 36 weeks.

But while Tana's Navy doctors suspected IUGR during an Aug. 31 visit, they didn't conduct an ultrasound exam until two weeks later. That check confirmed the fetus' lack of growth, as well as a normally beating heart. But Tana grew nervous when a doctor had her lie back down to do another ultrasound before assuring her that "everything looks fine and normal."

The following day, she and her husband, Aviation Structural Mechanic 1st Class Scott Graziani, thought they felt the fetus move. But on Saturday morning - Sept. 16, 2000 - Tana became concerned.

"There was no cramping, no pain, no nothin'," Tana said. "There was no soul. There was an empty feeling in my stomach. I just had a sense that there was nothing there."

At the hospital, doctors confirmed the worst: no heartbeat.

Tana, understandably upset, asked for a C-section delivery but was told she'd have to come back that night for an induced vaginal delivery.

During the procedure, she said she was given no pain pills and no ice chips, and the couple maintains that the doctor had her back turned when a friend, who'd come along to help, caught Anthony in a sheet as the boy, all of 4 pounds, 3.2 ounces, slipped lifelessly out of Tana.

If doctors had earlier induced labor or performed a C-section, family attorney Chad Roberts argued, the baby could have been saved.

"She never should have gone home from here [after the ultrasound]," Roberts said.

Roberts also argued that doctors failed to diagnose and treat the IUGR; failed to refer Tana to an obstetrics specialist; failed to communicate with one another about her baby's condition; failed to order appropriate prenatal tests; and failed to advise Tana about her baby's condition so she could make an informed decision about continuing the pregnancy or having an early delivery.

Tana and Scott sued the government for negligence. Both sides worked out an undisclosed cash settlement to avoid a court case.

"It was definitely a very miserable experience," said Scott, who says he now advises shipmates whose spouses become pregnant, "I don't care what it costs. Go out in town."

Improving day by day

Nearly 10 years ago, Defense Department officials acknowledged that military health care deserved criticism in the 1970s and 1980s. One official was quoted in a Defense Department press release as saying that the end of the military draft and the inability to pay adequate salaries produced a wave of physicians entering the service who "might not be the best of the best."

John Mazzuchi, then the deputy assistant secretary of defense for clinical services, also said the military offered a haven from rising malpractice insurance costs and that "we did not access the best people."

The Defense Department revamped training and began requiring its physicians to pass state licensing exams in 1988. By the late 1990s, he said, those problems had ended.

According to Jacksonville Naval Hospital officials, the hospital is repairing its problems. Jacksonville was accredited "without recommendations for improvement" by the Joint Commission on Accreditation of Healthcare Organizations on July 30, meeting the organization's safety goals in areas such as implementing the Universal Protocol aimed at eliminating "wrong site, wrong procedure, wrong person surgery." Other goals include removing high-risk medications from patient care units and assuring that infusion pumps release the proper amount of medicine in a specific period of time.

The accreditation by the JCAHO, the world's leading accrediting body, was earned following what Bono called a no-notice inspection that also focused on three areas of care: heart failure, pneumonia and pregnancy.

According to the JCAHO report dated Jan. 12, 2006, Jacksonville performed similarly to other accredited organizations in the category of pneumonia care, with an average rating. But it fell short in the category of overall quality of care provided to heart failure patients.

For instance, only 75 percent of heart failure patients had the function of the main pumping chamber of the heart - the left ventricle - checked while hospitalized. The state and national averages were 89 and 90 percent, respectively. And only 21 percent of eligible patients received specific discharge instructions about their condition, the JCAHO found. But all six eligible Jacksonville heart failure patients were given "ace inhibitor" medicine upon discharge, a medication that reduces the risk of returning to the hospital. The state and national averages were 79 and 82 percent.

Jacksonville scored much better than average in the category of inpatient neonatal mortality, losing only 0.08 percent of 1,190 patients versus 0.36 percent statewide and 0.38 percent nationwide. But it reported a higher-than-average 4.93 percent of childbirth patients suffering third- or fourth-degree vaginal tears during delivery. The statewide average was 3.29 percent of all women delivering children, with the national average at 4.19, according to the JCAHO.

The last three times the JCAHO rated Jacksonville Naval Hospital, it initially gave the hospital "accreditation with requirements for improvement" in the areas rated during those years. Those were the overall hospital and its pathology and clinical laboratory in both 1997 and 2000, and the pathology and clinical laboratory in 2002. Each time, within seven months, Jacksonville earned full accreditation from the JCAHO.

The string of 2005 cases Cronin has accepted or continues to consider would seem to indicate continued problems at Jacksonville, however. And those involved in the cases have begun speaking out in anger over doctors who were named in settled or adjudicated malpractice lawsuits who are still practicing medicine, either in the Navy or in private practice.

"I don't want to see this happen to any other family members, as well as my family," said Jessica Hugaboom, who is nearly eight months pregnant and now lives in the greater Norfolk, Va., area, served by Portsmouth Naval Hospital. "I don't know whether or not I want to trust the naval hospital. I have mixed emotions about it."

Bono's new strategic plan to improve service at Jacksonville appears aimed at the very same problems that led to most, if not all, of the malpractice incidents over the past six years. She wants the hospital to begin practicing "evidence-based medicine": taking a focused measure of a patient's needs and doing wide-ranging, systematic research that, in tandem with a doctor's clinical expertise, will discover the best possible treatment options. The plan states that health services "will be coordinated to improve clinical outcomes."

The ultimate goal, Bono said, is to provide "patient-centered quality health care," a system under which patients, families and hospital staff "plan and coordinate health care and services in a collaborative manner," she said.

Evidence-based medicine and medical team training, two key prongs in Bono's plan, are not unique to Jacksonville. According to Arthur, "All our facilities have those two things as priorities." When asked if they had previously been implemented at Jacksonville, he replied, "I don't know if they had or not. If they had, it doesn't sound like it's [been] all that effective." When asked if he was aware of whether his priorities were being implemented at other naval hospitals, he replied, "Implementation of such tools is a continuous, evolving process in all our facilities."

The initiative to convert medical records to digital form will clearly be an advance over paper records. Arthur said he expects the Navy's nonretiree records to be fully digitized within the next five years.

Arthur said he feels Bono is on the right track, saying her changes "are exactly the right ones to make. I also fully understand that the changes will not result in immediate improvements across the board, nor will they change public perception overnight. The way we will change public perception is by being better at what we do, day after day."

But while that process ensues, he said, "I do expect that that facility will take a hard, internal look at how it views its patients, its customers and its duty to the community."

Record of confusion

Glenda Hines was admitted to Jacksonville Naval Hospital on April 8, 2003, for a routine hip replacement.

Hines had experienced increasing problems with her degenerated right hip for four years. During her preoperative evaluation, she had an abnormal EKG. According to depositions taken by Cronin, the family attorney, the certified registered nurse anesthesiologist, Cmdr. Joseph Kelly, went to the lead anesthesiologist on the floor, now-Capt. Robert Dennison, to get his approval to anesthetize Hines for that day's surgery. Dennison, Cronin said, claimed that it was Kelly's responsibility to make the choice, but that he ultimately approved of the decision to proceed.

During the operation, Hines' blood pressure dropped. Expert witness and board-certified physician Joseph Varon said in his report for the plaintiff that the abnormal EKG and the subsequent low blood pressure detected during surgery should have indicated a lack of blood flow to the heart. This was confirmed by a second EKG following surgery.

The prolonged low blood pressure starved Hines of oxygen, and she suffered irreversible brain damage in the recovery room, the legal complaint charges. The following day, she developed a pulmonary edema, or fluid accumulation in the lungs, but the Navy doctors failed to take standard measures, such as administering diuretics, which help reduce the amount of water in the body.

Six weeks later, she was dead. Now, nearly three years later, retired Signalman First Class Dwight Hines lives in despair in a plain, white, collapsible 22-foot trailer parked behind the Moose Club in Macclenny, Fla. He sold the house he shared with his wife of 38 years because he couldn't bear the pain.

"I'm in limbo," he said. "To be blunt, this has ruined my life."

A second expert witness said the doctors failed to meet the standard of care because they should have recognized that Hines was at "intermediate to high risk" for coronary heart disease before attempting the surgery.

"The records should have clearly reflected that she was not approved for surgery and communicated to the anesthesia and surgery personnel," wrote Arthur Herold, an associate professor of medicine at the University of South Florida College of Medicine. "Also, there should have been clear communication with the cardiologist.

"Instead, what we have is a record of confusion, lack of documentation and lack of acknowledging and recording this patient's risks for coronary heart disease."

The case is scheduled to come to trial on July 6, 2007. Meanwhile, Hines still goes to Jacksonville to get his aches and pains taken care of.

But when he does, he can't shake what happened.

"That's in the back of my mind," he said.

And that's a devastating conflict for Hines.

"I'm a Navy man," he said. "I always have been."

And Glenda was always there. "She was a good Navy wife," he said.

The tears begin to flow. "And I really miss her."

[utahdoc]

In the interest of full disclosure I am LT CDR Stacy McBroom and I would like to clarify some of the statements made by Mrs. Perez. First of all she has been impugning my name however let me make clear that she did sue the gynecologist and that case was settled out of court. She did not sue me nor was I ever named in a lawsuit for the simple reason that there was no malpractice on my part. She presented to me and was properly diagnosed with problems that were a result of her hysterectomy. I was not involved in that surgery at all. The statement that the operation nearly killed her is a gross overstatement. She had been properly consented prior to the surgery with one of the complications listed as an injury to the major blood vessels. Due to all the scar tissue this did occur however it was promptly repaired. Her statement that blood gushed everywhere is interesting as I was there and this was not the case. She did have a small heart attack however she had no loss of heart function due to this and as memory serves me she was discharged from the hosptial about five or six days after the surgery which is fairly standard for that type of surgery.
I understand they are angry with what has happened but I don't understand why continue to slander me when I diagnosed her properly. She does have some problems however these are not a result of my surgery.