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After a review of some records, here is my recollection of the events of my mother's death and some of the results of the investigation(s). At the time of her death mom had been a longtime employee of L.A. County and worked in L.A City Hall. She had also been nominated as "Disabled Employee of the Year." Her sister Ruth, with whom she'd lived for 15 years or more, had passed away a week earlier. Mom sang Amazing Grace at Ruth's funeral, adding, "Ruth, I'll see you soon in Heaven"
But this time the pain was more intense, so Mom downed a pain pill and drove herself to Kaiser.
The "pain pill" turned out to be, in fact, a sedative; en route to the hospital she fell asleep and crashed into a parked car, being transported to Glendale Adventist Hospital via ambulance before being transferred to Kaiser Sunset, in Hollywood.
Mom sounded awful in my phone conversations with her-- I live in Washington -- but I received assurance that all was okay: just cracked ribs and esophageal reflux; Mom was scheduled for release on March 30 for outpatient treatment. Her "doctor said Mylanta," so to speak.
Just after 9 PM my sister, who lives in Los Angeles, called. She was bawling and barely able to speak. She cried out simply, "Mom's dead."
She didn't know what had happened: she had been told Mom had been found "dead in her bed," a scenario latter described to me by a physician who had attended the code blue. The doctor said, (paraphrasing) "A nurse reportedly found her in bed, unable to resuscitate."
Within an hour it had become evident that the hospital's story might be less than truthful.
I spoke with Mom's closet friend Phyllis, who told me that for a period of some 45 minutes Mom had been calling her, crying out, "They're killing me, I'm dying, no one will help...." Phyllis and her husband Jay contacted the 5th floor nurses station and then called their pastor to ask for prayer. They hadn't thought to call me or my sister or brother.
One of employees at the nurses station had made an odd remark to my sister: "I'm sorry about what happened to your mom. I was here and heard all about it." About what-- someone being found dead in bed, or some incident resulting in death?
Days later I called the employee who had made the statement to my sister. Sugarcoating every word, I told her I had hoped that my sister had not acted rude to her (she hadn't), asking further if I may have the hospital address, so that I might send flowers and a "thank you" card to express my appreciation for all that the medical staff had done in trying to save my mother. The employee paused briefly and said in a low voice, (paraphrasing) "As an employee of this hospital I cannot say anything. But as a concerned citizen of Los Angeles, I feel it is my duty to advise you to investigate." She would say no more.
I did not want to go through the huge expense of hiring a private investigator, but with a death certificate in hand that stated "manner of death natural, cause of death Sudden Death" I could not interest any medical malpractice (MMP) firms in reviewing the case. The Kaiser medical staff had already circled the wagons, making obtaining any information from Kaiser's end a seeming impossibility. Even Mom's own doctor would say no more than seven words: "I really liked your mom. I'm sorry."
Acting on the advice of someone within the L.A. DA's office, on April 9,1994, I formally put Kaiser on notice that I sought access to Mom's record via a California law (section 1158) that requires medical providers to release such record within a week of the request. Kaiser either could not or would not provide the record.
The private investigation was conducted by a retired FBI agent who had held the agency record for most arrests under the Mann Act... and the woman I wanted most in the world for him to find was the nurse who had reportedly "found" Mom "dead in bed." The investigator moved with lightening speed, first locating and interviewing the Kaiser employee who had come forward with the red flag. That employee would later file a complaint against me for the "unprofessional" demeanor shown her by my investigator, as the Kaiser attorney put it. (In fact, in addition to being a retired FBI agent, one who worked "Special" on some publicly noteworthy cases, my investigator was licensed by the state of California and had come recommended by people associated with the Academy Awards who employed the detective to locate missing cast members of old films and the like.)
The investigator also determined via an informant that the nurse in charge of Mom's room, Room 512-B, was away on an extended trip and therefore could not be interviewed. He was also unable to locate the 5th floor nursing supervisor, who according to investigation moved with her her family from their condo two weeks after Mom's death. The investigation concluded that the nursing supervisor was still believed to be employed by Kaiser.
On May 25, I advised Kaiser Sunset's records department in writing that I would take steps necessary to force them to comply with my April 9 request for the medical record. A week later, on June 2, fifty-four days after I had requested the record I finally had received it. I poured over every entry, stopping at the last nursing log entry (exact quote): "2045 Pt. found standing @ edge of bed attempting to walk, put pt. back to bed & call for assistance, while pulling pt. upon bed pt. pass out, O2 by NC 100%, called for code blue." (O2 by NC... Oxygen by nasal cannula)
Mom had not been "found dead in her bed." She had been trying to leave her room, ostensibly to obtain help.
The nurse's signature was illegible on every note that she had signed but the Resuscitation Report report listed it clearly. I'm not going to use the nurse's real name here, rather I will use an analogy. The nurse was a Latino with a very common last name that is only one letter's difference from another common Latino surname... the difference between a name like Gardner and Gardener, for example. The Resuscitation Record listed her as "Gardner."
My investigator faxed me a warning: "The following information was received from a confidential source of reliability: REF: "GARDNER" "GARDNER" IS NOT LICENSED WITH THE STATE OF CALIFORNIA AS A LICENSED VOCATIONAL NURSE."
The investigator interviewed another nurse named in the Resuscitation Report, and in doing so he mentioned "Gardner's" name. The nurse advised him that the nurses' association had called a meeting, during which the incident was discussed, adding that she doubted anyone would agree to discuss the matter further. The investigator noted that the nurse did not disagree with the name "Gardner."
On a hunch, the investigator decided to check out the name "Gardener" (keep in mind that this is just an analogy-- the woman has an Hispanic name) and hit the jackpot. He drove some 2 hours east of L.A. to find Ms "Gardener" and she agreed to be interviewed in her home. Based on decades of experience as an FBI agent and private investigator, after the interview my investigator advised me that he believed the nurse was forthcoming, truthful, open and spontaneous.
Weeks before Mom's death this nurse had tendered her resignation to Kaiser so that she could work at a hospital closer to her home; by coincidence, her last night on the job was the night that my mother died. The nurse explained that an orderly cleaning up a spill had found my mother trying to walk from her bed; my mother being an amputee (leg), one of the nurse's first duties was to insure that Mom was put back to bed before she could fall and hurt herself. Mom was literally hopping on one leg.
The nurse laughed when shown the Resuscitation Report and said that she could not offer an explanation as to why her name had been misspelled.
The investigator was satisfied that Mom's death was not a matter of malpractice and thereafter I discharged him... though we had a tense argument about the thoroughness of his line of questioning. And I still wondered why the hospital had spun the "found dead in bed" story. There was also the matter of the medical record, which the hospital had maintained for nearly two months could not be located.
I was also very troubled by the Death Summary prepared by Mom's physician. California law required that Kaiser provide me with the medical record by April 24, but the record could not be found; thus I did not receive it until June 2... and yet the Death Summary in that record was dated 5/17/94, written more than a month after I was legally entitled to the record.
Much to my surprise, the Death Summary states that Mom was "followed by psychiatry for her bipolar illness and also the recent motor vehicle crash that left her quite upset." True, Mom had manic-depression, but it had not manifested itself in years. There is no record of treatment for, or observation of, bipolar illness on the record anywhere else, nor is there a mention of her being upset about the car crash. The Psycho-Social record states "no" to all of the conditions listed: "Angry, Anxious, Combative, Denial, Depressed, Fearful, Flat Effect, Hostile, Hyperactive, Hysterical, Irritable, Manipulative, Suspicious." The only other condition listed is "Calm," which is checked "yes." The Psycho-Social log recorded during Mom's last days did not agree with the Death Summary observations of bipolar illness and being upset.
The doctor concluded the Death Summary with: "On the evening of 3/29/94 the patient was found without pulse, not breathing... and (after ACLS) was pronounced dead at 9:25 P.M."
During late 1994 I struck a verbal deal with a Kaiser representative named ______. I promised _____ that I would turn over the results of my investigation if the Kaiser Administration would answer some questions that I had prepared. I gave my word that in the event Kaiser agreed, I would forgo the right to pursue a legal action. _____did not represent that she had the capacity to agree to such, but did state that she would present the offer to the *proper authority.*
I submitted my list of questions in early 1995: _____ asked if I were still willing to forgo a formal action and I replied "yes."
Weeks later, in a letter dated April 12, 1995 *: advised: "We do not believe that it would be appropriate for us to comment on the issues you raised concerning your mother's medical care."* Although past the one year statute of limitations for filing a wrongful death claim, I responded to _____ letter by filing such a claim, in Pasadena, citing a tolling of the statute via the "discovery" provision. I served as representative for the arbitration action; though I am not an attorney, in this matter of my mother's death, my personal interests and motives put me in a position to better represent those interests and motives: I did not want to win a financial settlement, I wanted the truth, as did my sister and brother.
I withdrew the action in late summer 1995. The legal firm representing Kaiser drew up the Dismissal which was signed by me (executor), my sister and my brother. Kaiser's attorney was not suitably amused by my sister's signature on the Dismissal, which was "X--KAISER PERMANENTE MAIMS AND KILLS!" I told the lawyer that my sister was more than willing to legally change her name, if that's how Kaiser wanted to play it.
And that's how the Dismissal reads to this day, with my sister's name shown as "X-- KAISER PERMANENTE MAIMS AND KILLS!"
Acquaintances and others in the media had quietly followed the investigation of the unusual events attached to my mother's death in Room 512-B.
1. Section 70211 (a) (1) Nursing Services: "A patient admitted with pain related to cardiac problems and fractured ribs failed to have an appropriate assessment mechanism in place for their pain and failed to have established objectives in place for differentiating the nature of the pain and treatment."
2. Section 70213 (d) Nursing Services General: "A patient was admitted to the facility on 3/27/with epigastric pain and chest pain. The patient was status post motor vehicle accident and had been diagnosed with rib fractures. The care plan did not differentiate between pain caused by the fractured ribs and cardiac pain..."
3. Section 70413 (g) Basic Medical Service: "Based on a review of the emergency medical record, there was no emergency physician record/evaluation for one patient... An admitting history and physical was done, however, it cannot be substituted for an emergency room evaluation."
4. Section 70749 (a) (6) (A) (B) Patient Health Record Content: "On 3/29/94 at 2045, it was documented by nursing in one patient's record that the "patient was found standing at the the edge of their bed..", THERE WAS NO OTHER RECORD OF PERTINENT OBSERVATIONS, INCLUDING PHYSICAL MANIFESTATIONS AND RELEVANT NURSING INTERPRETATIONS OF SUCH OBSERVATIONS REGARDING THIS EVENT." (emphasis added)
5. Section 1795.12 (b) of The Health and Safety Code, Inspection and Copying; retention and quality of records; liability discrimination; violations: ..."Any patient or patient's representative shall be entitled to copies of all or any portion of the patient's records... within 15 days after receiving the written request. This requirment wasnot met... the facility failed to transmit copies of a health care record.... The 'Request For Access to, or Copies of Medical Records' was filled out and signed by the requesting party on 4/9/94, however, the records were not provided until June 2, 1994."
Beyond the formal sanctions, the DHS investigator told me that my mother's incessant use of the call button (to summon nurses for pain management) resulted in her being labeled as an "abusive patient" -- an attention seeker, one prone to theatrics, perhaps. Medical staff apparently are less likely to heed the calls of an "abusive patient," which may account for the reason that Mom felt that "no one," would help her in her in the moments before her death, and which may have prompted her to seek help by phoning friends, and to ultimately get out of her bed to seek assistance within the hospital.
None of the above necessarily indicates medical malpractice, for I can't know if my mother would have survived under the care of any other medical facility.
What is known is that Kaiser made mistakes; that the events of my mother's death were swept under the rug; that I and my siblings spent a small fortune to discover at least this much truth: that Mom died in agony, at age 59; that for at least 45 minutes she cried out for help; that Kaiserstaff lied when they told us she'd been found dead in her bed...
And that more recently, in my opinion, my old dog Fozzy died with more dignity.
In accordance with her previously stated wishes, I scattered Mom's ashes on April 30, 1994, at my forest property while a bagpipe played Amazing Grace. A bronze marker located under a ponderosa states: "This tree grows in loving memory of our Mother, __________(Name omitted out of respect for members of the family) August 7,1934 - March 29, 1994: Here Forever with the The Wind, the Trees and the Stars."