Kaiser Permanente harmed little Richard Leonard during routine ear surgery

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COLUMN ONE Medicine's Fatal Code of Silence Eight-year-old Richard Leonard was undergoing `minor surgery' when he died at a Denver hospital. His anesthesiologist was known as a problem. But the peer review system kept his parents in the dark. Series: Medicine's Fatal Code of Silence. FIRST OF TWO PARTS.; [Home Edition]

BARRY SIEGEL. Los Angeles Times (pre-1997 Fulltext)Los Angeles, Calif.: Aug 24, 1995. pg. 1

Abstract (Summary)

Verbrugge, after taking a medical history, left to scrub and dress. Nurse Mary Kay Harrell eased Richard into a wheelchair, rolled him toward an elevator. China walked by her son, he was so quiet and tense. At Operating Room 7, she watched him disappear through the swinging double doors.

Much has transpired since Richard's death. An outraged doctor has blown the whistle on his colleague, inspiring an investigation and hearing. Colorado's Board of Medical Examiners has revoked Verbrugge's license. Denver's district attorney has charged Verbrugge with reckless manslaughter, an extraordinary action. With the trial pending, debates wage now over peer review secrecy, the medical profession's self-policing and criminal prosecutions of doctors.

By several colleagues' accounts, he also was not a person who remained ever-alert in operating rooms. After Richard's death, Verbrugge would tell a psychiatrist it was possible that some of the St. Joseph staff reports about him "nodding off" were accurate, related to sleep deprivation and family stress. At the medical board hearing into Richard's death, Verbrugge would testify that "in one particular case, I talked to the surgeon, he said he saw me nodding off . . . . I acknowledged the possibility." He tried not to fall asleep, but "I'm sure I have . . . . Once in a five-hour operation, the lights were down, there was absolutely nothing for me to do."

From the moment China Leonard met Dr. Joseph Verbrugge Jr., she didn't like him. They were in a pre-op room at Denver's St. Joseph Hospital, where China's son Richard, 8, was being prepared for minor ear surgery. It was 7:15 a.m. on July 8, 1993. Verbrugge, the scheduled anesthesiologist, had rushed in late, acting bristly and abrupt.

"Well, are you nervous?" Verbrugge demanded of Richard.

Richard didn't look up from the television. He'd been uncommonly subdued all morning. Not once had China seen him cock his head and ask the customary barrage of questions.

"Richard," Verbrugge demanded, "look at me."

Richard kept his eye on the TV.

Verbrugge shrugged, rolled his eyes at China, muttered something about kids and TV.

China reached for her son. He was quiet, she knew, because he was scared. This doctor seemed so curt, so unpleasant. An impulse to cancel the operation fleetingly crossed her mind. She shook it off.

It didn't matter about this doctor's personality, she reasoned. She couldn't judge anything by that. They were at one of the best hospitals in Colorado, top-ranked by professional groups and consumers. The oldest private teaching hospital in Denver, St. Joseph had been owned by the Sisters of Charity since 1873.

You have to assume you're in safe hands, China Leonard told herself. You have to assume this doctor is good.

Although there was no possible way for her to know it, China's instincts about Verbrugge at this moment were far more reliable than her assumptions about the medical system.

For years, Verbrugge's hospital colleagues had been finding him just as difficult and abrasive as did China. Worse yet, they'd grown increasingly bothered by his inattentive behavior during surgeries. In fact, on at least six occasions since September, 1990, they'd informed the hospital that he appeared to be sleeping during operations.

Verbrugge had never been sued, though, or suspended, or reported to the state Board of Medical Examiners. St. Joseph had handled the anesthesiologist's problems internally, through the hospital's private, confidential peer review process. To do otherwise would have involved hearings, lawyers, confrontations, tarnished careers.

So no one beyond the local medical community knew about Verbrugge's problems. And no one could know. Even if she'd raised questions, China would have heard nothing untoward. She could not have foreseen that she and her husband were about to receive a terrible, involuntary education concerning the ways of medicine when it goes wrong.

Sitting in the pre-op room, China reassured her son. You'll be asleep soon, she whispered. Before you know, it will be over. Think of what we'll do afterward. Swimming parties, the zoo.

That would be the last moment she saw her son alive.

Yet who finally is responsible for Richard Leonard's death remains a largely unexamined question. Only Verbrugge faces a criminal trial. Elsewhere a shaken medical community, watching from behind the protective barrier of lawyers and peer review privileges, is left to contemplate privately its role in Richard's death. The question of broader moral responsibility begs still for consideration.

The Leonards' tragic loss is finally a story about doctors, nurses and administrators who knew they had a problem physician on their hands but failed to find a way to handle him, or stop him.

"This was not about a good doctor having a bad day," observed the physician who blew the whistle on Verbrugge. "This was about a bad guy having a terrible day."

A Troublesome Ear

By the time Richard arrived at St. Joseph on July 8, he and his family were thoroughly familiar with hospitals. For years, Richard had been plagued by ear infections that resisted antibiotics. When he was 3, doctors put tubes in his ears, to help drainage, in a 20-minute operation under general anesthesia. Later, an infection required them to remove one tube in a second brief operation, also under general anesthesia.

Eventually, due to repeated infections, skin tissue started growing inside Richard's right ear. It wouldn't stop growing. "Elective surgery," the doctors called the operation to remove it. Sooner or later, though, the skin had to go.

Sooner, the Leonards decided. The sooner Richard's impaired hearing could be corrected, the better.

The operation, a tympanoplasty and mastoidectomy, would be delicate, meticulous and long, up to four hours. It would involve the removal of the eardrum, drilling, scraping, reconstruction. But for all that, it was considered by doctors a minor procedure, with low risk.

The Leonards, who own a specialized software company, had enrolled their employees in the Kaiser Permanente medical plan, which in Denver contracts for hospital beds, chiefly at St. Joseph. Under Kaiser the Leonards had their choice of the group's surgeons. Their pediatrician recommended Dr. Patrick G. McCallion.

China and Jay Leonard liked him when they met. McCallion was just 31, but he appeared knowledgeable. He'd done this type of surgery many times before. He was patient, thorough, didn't seem bothered when China peppered him with questions. He reassured them when Jay asked about risk.

The Leonards didn't inquire about anesthesiologists, and McCallion didn't work regularly with one in particular. Under the Kaiser plan, the Leonards could have interviewed candidates, but it never occurred to them. Richard, after all, had undergone general anesthesia twice before, and so had others in the family. They took the anesthesia process for granted.

Pre-Op Play Days

So the days before Richard's surgery unfolded with little apprehension. Richard spent most of his waking hours with his neighbor and best friend, Michael Kalousek.

They preferred the outdoors to TV or computers. They climbed 50-foot trees, they hiked, they scrambled up big rocks. They rode bikes and hid in fields, pretending the dinosaurs from "Jurassic Park" were after them. They made up stories, built Lego structures, hung high on a rope swing over a nearby lake. Above all, Richard drew and drew-dinosaurs, monsters, space aliens-and promised to teach Michael how to draw as well.

To Michael's parents, Richard was their son's natural soulmate, an elfin, ever-curious "sparkler." The two boys even gave each other gifts; one day Michael came home with a backpack stuffed with Richard's small plastic dinosaurs.

At dusk on July 6, two days before Richard's surgery, the two boys traded bikes. Richard let Michael have his new chrome multi-gear bike while he took Michael's old single-gear; he could do wheelies better with it. "You can have my bike for a few days," Richard said. "Then I want it back."

The next morning, Richard walked around their neighborhood, telling everyone how he'd be able to hear better once this operation was done. Then he and his mother went to St. Joseph for a pre-op meeting with their surgeon. "That's when we should have met the anesthesiologist," China would say later. "If we'd met, and I saw I didn't like him, we could have changed. But he wasn't there."

In fact, he probably hadn't yet been selected. Kaiser's 25 anesthesiologists were all booked for the next day. In such situations, an independent group of doctors, Colorado Anesthesia Consultants, accepts Kaiser's overflow on a contractual basis. Whoever is available in that group gets assigned.

It was, in other words, a twist of fate that on the afternoon before Richard's surgery, Dr. Verbrugge, a charter member of Colorado Anesthesia Consultants, drew the assignment to oversee the 8-year-old's anesthesia care.

A good deal about Verbrugge's career still remains obscured behind peer review confidentiality. From what is available, though, it is possible to draw a portrait of the anesthesiologist on the eve of Richard's surgery.

He was then 53 and divorced, with four children. He was raised in Michigan and had taken his internship and residency in Colorado. He'd been practicing in Denver for 20 years. He'd served as a general medical officer in Vietnam with the U.S. Navy from 1967 to 1969. He'd held assorted positions in the Colorado Society of Anesthesiologists. He enjoyed music, fishing and investing, and volunteered widely as physician for high school athletic teams.

He also struggled with chronic depression, his psychiatrists said later. Much of it related to family problems. After a difficult 20-year marriage, his wife had left him in June, 1991, and divorced him in September, 1992. Since then, he'd dealt regularly with two troubled teen-age sons.

Apart from depression, Verbrugge suffered from what his doctors later called a "personality disorder" and friends called a "communications" problem. By that they meant Verbrugge antagonized those about him. "He's not a person you warm to easily," is how his former neighbor and attorney, Raymond Miller, put it.

On the day he was assigned to Richard's operation, Verbrugge's problems clearly weren't a secret in the Denver medical community. Interviews and documents indicate that he'd had a history of reprimands, that some surgeons flatly refused to work with him, that his own medical group knew he'd likely dozed during operations. St. Joseph Hospital officials, at the least, understood they were dealing with a troubled anesthesiologist.

On "various occasions," according to court documents, St. Joseph had "admonished and counseled" Verbrugge concerning "incidents of sleeping and other alleged aspects of disruptive attitude and behavior." Six months before Richard's operation, matters had so deteriorated that St. Joseph's medical director, Bruce Jensen, talked to Verbrugge about his assorted problems and raised questions about possible substance abuse.

That was all St. Joseph did, though. To do more, to suspend or limit Verbrugge's privileges, would have required hearings, due process, lawyers, possible litigation. It also would have required reporting Verbrugge to the National Practitioners Data Bank and the state Board of Medical Examiners.

The hospital either didn't see cause for such action or chose to avoid the hearing room. It usually does: St. Joseph suspends a doctor only once or twice a year, usually for substance abuse. Most with problems either resign before an investigation or agree to continuing education.

Although Verbrugge's record was far from spotless, it apparently contained no recognized disasters, no unqualified casualties and no proof of substance abuse. In fact, he'd regularly passed St. Joseph's quality assurance reviews. Every two years, after considering such factors as "behavior in the hospital" and "capacity to satisfactorily treat patients," St. Joseph had re-credentialed him.

What to do if a problem physician, over years of practice, has never actually had what the hospital considers a "bad outcome?" Where to draw the line?

"Medicine is not just black and white," Sister Marianna Bauder, president of St. Joseph, observed recently. "It's a matter of judgments. We're dealing with human beings. Human beings can make mistakes. We have 1,250 doctors on staff. They are all human. If we think there is danger to a patient, we can initiate. We do. But again, we're not talking black and white."

With no "danger to a patient" detected, Verbrugge's assignment to a minor ear operation passed routinely through channels late on the afternoon of July 7.

That night "was not a problem," Verbrugge would later say. He got a good night's sleep, he was not drowsy the next morning.

The Leonard family also passed a routine evening. Jay and China took Richard and his older brother, Ted, 10, out to dinner at the Traildust Steakhouse, one of Richard's favorites, a big informal barn of a place with a slide and a country band. Near 10:30 p.m., Richard fell asleep in the car on the way home. Too tired to make it to his bedroom, he curled up on the living room couch.

China and Richard, due at the hospital by 6 a.m., were going to leave home before Jay awoke. With a customer from Halifax, Canada, in town and a software product due out, Jay planned to work in the morning, then join his family at midday, when Richard was to emerge from the anesthesia.

In the living room, the father watched his younger son sleep. Later, Jay would say he had a premonition just then, a sense that something wasn't right. For whatever the reason, before retiring, he walked over to the sofa and touched Richard lightly on the back. It would be the last moment he saw his son alive.

Inside O.R. 7

Nurse Mary Kay Harrell wheeled Richard into the operating room at 7:40 a.m. She eased him onto the operating table and comforted him, for Richard was crying. Everything will be OK, she reassured him.

Anesthesia induction began at 7:45 a.m.

First, Verbrugge attached a heart monitor to Richard. Then he turned on the machines that measure pulse, oxygen and carbon dioxide levels. Finally, he placed an inhalation mask on Richard's face, and started the flow of 100% oxygen mixed with a small amount of the anesthetic halothane.

Richard resisted, a little uncomfortable with the mask, so Verbrugge let him hold it as he briefly increased the halothane ratio. When his patient had settled into sleep, Verbrugge placed an endotracheal, or ET, tube down Richard's windpipe, to assure proper delivery of gases and expiration of carbon dioxide. For monitoring purposes, he also inserted an internal stethoscope and temperature probe-a soft blunt tube-into Richard's esophagus.

Already, Verbrugge's conduct was raising eyebrows in the operating room.

Accepted standard of care calls for anethesiologists to listen to their patient's chest with a stethoscope after inserting an ET tube, to assure they have a properly placed airway. Verbrugge would later say he was "pretty sure" he did that. But two nurses who were standing nearby would later testify that they never saw Verbrugge use a stethoscope then or at any time during the operation.

Nor did they see Verbrugge hook the internal temperature probe to a monitor. When he tried to, he found the probe's connector wasn't compatible. He asked for a suitable monitor.

It arrived within five minutes. By then, however, Richard was being prepared and draped for surgery, since Verbrugge hadn't asked the nurses and surgeon to wait. To connect the probe to the monitor would now require Verbrugge to lift the drapes. "Thank you, it's too late," Verbrugge told the attendant.

Unlike the temperature probe, the internal stethoscope had no compatibility problem with its monitor. But Verbrugge also chose not to connect it. He feared possibly violating the "sterile field," Verbrugge would later explain, even though neither the surgeon nor nurses thought that a possibility.

Surgery began at 8:20 a.m., with Verbrugge lacking a way to reliably, continuously monitor Richard's temperature, breath and heart sounds. To many anesthesiologists this situation would be unimaginable; textbooks call the temperature probe "routine and essential." At the start, though, it didn't seem to matter.

For the first hour and half, as the surgeon drilled into Richard's ear, the operation was "very, very routine," Nurse Harrell later recalled. Only as time went by did Richard's carbon dioxide concentrations start rising. Although not dire, this trend suggested a potential problem with ventilation. Richard possibly wasn't exhaling carbon dioxide effectively.

Rather than closely monitor this condition, Verbrugge apparently stopped observing it. After 9:30 a.m., Verbrugge failed to record on his chart a single carbon dioxide value for the rest of the operation.

Verbrugge also apparently relaxed his monitoring of Richard's pulse. His handwritten chart between 9 and 10 a.m. shows a flat line for one stretch, while a monitor in the operating room was recording a steadily rising heart rate. By 9:40 a.m., Richard's pulse was 20% higher than at the operation's start.

Verbrugge says he was still monitoring Richard, he just wasn't fully charting what he observed. The nurses in the operating room think differently, and so does the administrative law judge who presided at Verbrugge's hearing.

Nurses Harrell and Karen Latson say they saw Verbrugge between 9:30 and 10 a.m. slumped in his chair, his head on his chin, his eyes closed, his arms crossed in front of him. On several occasions, Latson noted that his head bobbed from side to side.

Latson stared hard at Verbrugge, who didn't respond. She grew convinced he was asleep.

Harrell would later testify, "I was hoping he wasn't."

Verbrugge insists he was awake. At the conclusion of the hearing into Richard's death, however, administrative law judge Judith F. Schulman found that Verbrugge "on various occasions was asleep for short periods of time or otherwise failed to remain alert and vigilant."

Apparently, neither nurse said anything during this 30-minute span to Verbrugge or the surgeon. They felt reluctant to mix it up with Verbrugge, both would later explain, for they knew him all too well. Latson had worked with Verbrugge about 10 times over seven years. Harrell had worked with him regularly since 1976, an average of six to eight times a year.

"I didn't feel comfortable saying anything because I was afraid of a confrontation," Latson testified. "Because Dr. Verbrugge has been known to exchange words with some of the staff members in the O.R., and it's just not something that you would want to do."

Verbrugge "has always been difficult to communicate with . . . ," Harrell testified. "It was very hard to get figures from him. And he would always give an argument why he didn't have the figures . . . . I think over the years I'm reluctant to approach him about things because, No. 1, I'm either going to get an argument or, No. 2, he doesn't think my comment is valid."

No One to Question

The surgeon operating on Richard also had worked with Verbrugge before. In a deposition, McCallion would later say he didn't observe Verbrugge much during this surgery because he was peering through a microscope, and didn't "recall" any problems with him. Both nurses, though, remember Verbrugge resisting several times when McCallion asked him to adjust the tilt of the operating table. "(Dr. Verbrugge) was reluctant to do so . . . ," Nurse Latson later testified. "It was just kind of a hassle."

At 10:15 a.m. the surgeon heard a gurgling sound from Richard and realized the airway tube had accidentally disconnected. According to the surgeon and Nurse Latson, they had to call out this problem to Verbrugge. The anesthesiologist insists he noticed it himself, just as they were warning him. In any event, Verbrugge rose as the anesthesia machine alarm began to ring, walked to the other end of the operating table, lifted the drapes around Richard and reconnected the tube.

A disconnect of this sort, possibly caused by a nurse's movements and accompanied by gurgling, suggests a displaced ET tube or one partially blocked by a liquid obstruction such as mucous. "It is imperative to assess if the tube is in the right place and unobstructed," Kaiser's chief of anesthesia, Dr. Michael Leonard (no relation to Jay and China), would later observe about this moment. "You must climb under the drapes, listen to the chest with a stethoscope."

By all accounts, however, Verbrugge didn't check Richard's breath sounds with a stethoscope. Instead, he went back to his monitors at the foot of the operating table and sat down.

Fifteen minutes later, at 10:30 a.m., the surgeon noticed that Richard was breathing so rapidly he couldn't operate on him. McCallion counted as he peered through his microscope into Richard's ear.

"The patient is breathing about 60 times a minute," the surgeon told his anesthesiologist.

Verbrugge disagreed. "No, the patient is breathing 53 times a minute."

Either level indicated extreme respiratory distress, which Verbrugge apparently hadn't noticed. The surgeon limited his response to the matter at hand. He was just then involved in the delicate process of dissecting the skin growth in Richard's ear.

"Can you do something to slow the breathing down because I can't do the surgery with the patient moving 60 times a minute," McCallion said.

"There's not much I can do," Verbrugge replied.

Above all others, it was this moment-described by McCallion and the nurses in deposition and hearing testimony-that most appalled Kaiser's Dr. Leonard when he later reconstructed the operation.

"If Dr. Verbrugge responded right at 10:30, this child would be alive today," Leonard testified. "To have a disconnect at 10:15, then grossly abnormal respiratory distress at 10:30, and not respond . . . . That is inconceivable to me. It didn't matter if it was 53 or 60 breaths. It was incredibly abnormal, and imperative at that point in time for the anesthesiologist to immediately intervene to assess what's going on in the patient."

There were two possible explanations, experts now say, for what was going on.

There are those, including Mike Leonard, who think a mucous plug was blocking Richard's ET tube, preventing him from exhaling carbon dioxide. At the same time, they believe, his heating blanket and airway heater were spiking his unmonitored temperature. Richard-completely draped, heated by two external sources, unable to fully exhale through a blocked tube-couldn't throw off carbon dioxide or heat.

There are others, among them Verbrugge, who think Richard was suffering from malignant hyperthermia, "the anesthesiologist's disease." MH is a rare genetic condition in which anesthetics trigger dramatically accelerated muscle metabolism, which in turn causes huge increases in carbon dioxide and heat production, and thus excessive levels of acid and potassium. These, in essence, poison the heart.

MH occurs once in every 15,000 anesthetic administrations to children. With an antidote, mortality is only 5% to 10%, and near zero if treated early. Once past the initial stage, though, MH becomes difficult if not impossible to stop.

Whether caused by MH or respiratory distress, all the experts agree Richard was in dire trouble. With accelerated respiratory and heart rates and rising carbon dioxide levels, his condition demanded a response.

Verbrugge took no action, though. He didn't take Richard's temperature, didn't order blood gases, didn't listen with a stethoscope.

No one else in the operating room responded either. The surgeon, peering through his microscope, continued to operate. Nurse Latson "at that time was getting concerned," but as in previous operations "chose to believe" Verbrugge competent.

At 10:45 a.m., Nurse Harrell heard tones on the pulse monitor that sounded like irregular heartbeats. She turned to Verbrugge. According to her testimony, she saw him sitting in front of the anesthesiology machine looking down, hands in front of him in his lap. He didn't look up or appear to react. This surprised her.

She stood behind Verbrugge, looking over his shoulder at the EKG monitor. She saw an usually tall group of heart waves but couldn't detect anything that explained the abnormal beats. Verbrugge didn't appear concerned, so Harrell returned to her station.

This irregular beat, most now agree, was a red flag. Richard was showing ominous signs of hyperkalemia, or excess potassium, which can stop the heart from conducting electrical impulses.

Verbrugge insists he then began manually to ventilate Richard, by squeezing a bag set into the anesthesia machine's breathing circuit. But the nurses and surgeon didn't see him do this, and the judge in her findings concluded he did not.

Looking back later, Kaiser's Dr. Mike Leonard thought it incomprehensible that Verbrugge didn't respond. Even if he was bagging manually, that was inadequate, that was dealing with symptoms, not the cause. "Literally, the house was on fire . . ." Leonard testified. "It's like waking up in your house with a room full of smoke, opening the window to let smoke out, going (back) to bed."

Shortly before 11 a.m., Verbrugge detected a more extreme heartbeat irregularity. He asked the surgeon to cease, said there was a problem. He gave Richard a dose of a drug called Xylocaine. The heartbeat worsened. Verbrugge administered the drug atropine.

At 11:02 a.m., Richard's heart stopped beating. Verbrugge called a "COR zero," a summons for the resuscitative team, and placed Richard on a ventilator.

Nurses pulled off the drapes as Verbrugge moved to Richard's head. Richard, he could see now, was pallid. Touching him for the first time since the operation began, he realized Richard was burning hot. He started calling for a temperature probe.

Within 20 seconds, Kaiser anesthesiologist Dr. Steve Snidach arrived in response to the emergency summons. Snidach turned off the ventilator in order to hand-ventilate Richard. When he tried to squeeze the anesthesia bag, though, he couldn't; there was extreme resistance in the breathing tube. Snidach announced this loudly, then checked for a pulse. He couldn't find one.

Verbrugge thumped Richard's chest and started chest compressions, all the while still calling for a temperature probe.

Why do you want that now? Snidach asked.

That Verbrugge was focusing first on temperature probes and CPR, rather than Richard's airway, greatly disturbed Snidach. "ABC" is the fundamental order anesthesiologists follow in crisis: airway, breathing, then circulation.

A minute later, a second Kaiser anesthesiologist, Dr. Mark Wilson, arrived. Both he and Snidach loudly asked for a stethoscope, several times. Verbrugge didn't respond.

Two minutes elapsed before a nurse finally found a stethoscope and gave it to Wilson. He couldn't hear any breath sounds. This he announced loudly.

Verbrugge pulled out Richard's ET tube, which, they now saw, was 50% obstructed by a mucous plug. Verbrugge would later suggest this obstruction resulted from the chest compressions administered after Richard's heart stopped; Mike Leonard and the administrative law judge thought that highly unlikely.

Whatever its genesis, the plug clearly was impeding Richard's breathing at this moment. After Verbrugge inserted a new ET tube, Wilson could hear good breath sounds. Snidach was able to squeeze the anesthesia bag and hand-ventilate the patient easily.

Looking at Verbrugge's charts, Wilson and Snidach realized they were fragmentary. This patient hasn't been charted, they called out.

Then Snidach noticed that the airway heater was set so high it was causing the breathing circuit's plastic tubing to start melting. He turned it off.

At 11:07 a.m., the staff finally connected the temperature probe to a monitor. Richard's temperature, they now could see, was 108.

Wilson drew a blood gas sample. Carbon dioxide and acid levels were sky-high-five times the norm for carbon dioxide, 10 times for acidity. To have such levels, Mike Leonard later calculated, Richard's ventilation had to have been stunted for up to 45 minutes. For 20 minutes, he couldn't have been breathing at all.

It would be hours before the doctors declared Richard dead, but the outcome was already clear.

Richard's heart was riddled with poisonous carbon dioxide. Richard's blood gases were incompatible with life.

The `Complications'

Shortly after 11 a.m., two agitated nurses approached China Leonard where she sat in a public waiting room with a friend, Mary Ann Wapels. "Something has happened," one of them said. "It's very life-threatening."

They led China and her friend into a smaller private waiting room. Through a wave of panic and shock, China heard the nurses explaining. It happened all of a sudden, they were saying. His heart just stopped.

Mary Ann went to call Jay Leonard. Just a week before, Richard had spent the night with her two children, hanging balloons and painting giant signs for a heavily marketed lemonade stand. "You have to get down here," she told Jay now. "There are complications."

At 11:18 a.m., as Jay was driving to St. Joseph, Richard's idle heart stirred into a faint rhythm but not one strong enough to pump blood. At 11:38 a.m., doctors placed electrical pads on his chest, meaning to drive his heart with an external pacemaker. Six minutes later, the pacemaker captured the heart, producing a rhythm. But Richard's heart still couldn't pump blood.

When Jay reached St. Joseph at 11:45 a.m., attendants ushered him into the private waiting room. The surgeon appeared. The operation was a success, but there's a problem with the anesthesiology, Jay recalled McCallion saying.

Verbrugge came in shortly afterward, introduced by McCallion. To the Leonards he looked like a shaken wreck. Verbrugge explained his procedures and talked about a "rare MH reaction," then returned to the operating room.

Soon, Jay and China were being visited by a steady stream of hospital personnel. Most tried to give positive reports, but Jay couldn't help notice that not one said Richard had revived. When St. Joseph's social service people arrived at 1:45 p.m., Jay shuddered. In a hospital, he reasoned, they were the sign of death.

By now, some 20 nurses and doctors were in Operating Room 7, helping to administer heart stimulants and MH antidotes. Just before 2 p.m., they stopped CPR and put Richard on a heart-lung bypass machine. In a process akin to kidney dialysis, they began running Richard's blood through a filtered system, aiming to clear it of the excess potassium and acidity.

A half hour later, McCallion visited the Leonards again. "He's not dead yet?" Jay implored. The surgeon shook his head. "I don't want to give you false hopes. It doesn't look good."

China and Jay were reeling, praying, crying. China crouched in a corner, in a fetal position, covering her head with her arms. "Another wave hits over you," she later recalled. "You get number and number. In the beginning, it's happening so quickly, so intensely, things don't register. First disbelief, then reality hits. You realize it could be true. It's panic and frantic, then denial and numbness. It cycles over and over. Waves of reality, then waves of numbness. It just goes on and on."

At 3 p.m., Jay called his two children's nanny, Katy, with the news. As they hung up, Katy heard a knock at the Leonards' front door. It was Richard's best friend, Michael, returning the new multi-gear bike he'd borrowed. Katy, crying, told Michael she'd open the garage door. Michael wondered why Katy was crying. A strange notion chilled him: Was Richard maybe dead?

At almost the same moment, Verbrugge also made a phone call. Leaving the operating room midway through the bypass procedure, saying he had to use the restroom, Verbrugge dialed St. Joseph medical director Bruce Jensen from a hallway phone. He did so, he explained later, because he felt "an element of negativity," what with his colleagues' comments about the temperature probe and incomplete charting. Since there'd been previous allegations about substance abuse, he told Jensen, he wanted a drug test.

In the operating room soon after, doctors began giving Richard packed red blood cells through the bypass pump. Four times they repeated the process over half an hour, battling a deepening anemia.

Finally, there was nothing more to do. At 3:55, after two hours of pumping, they turned off the bypass machine.

Richard's heart, for an instant, pulsed and pushed blood on its own. Then it stopped.

For all their labors, the doctors had never managed to get Richard's heart beating since it first arrested at 11 a.m. That, Dr. Leonard later concluded, was testimony to just how grave and prolonged an insult it had suffered. "It's very hard to kill an 8-year-old heart. The insult must have been going on for a long time."

At 4 p.m., Verbrugge declared Richard dead. He and McCallion went to tell Jay and China Leonard.

The Leonards asked to see their son. Nurses lead them into a recovery room. Richard looked as if he'd been dead a long time. "We walked in there," Jay recalled later. "Nurses were crying all around us. Richard was lying there. It was bad. Oh, it was bad."

`The Worst Day'

Verbrugge too was having a terrible time just then, on what he'd later call "the worst day of my life." As the Leonards stood over their son's body, a distraught Verbrugge sat in the operating room, scribbling rapidly on his fragmentary chart of Richard's operation. He was trying, he told nurse Delia Garcia, to record the events of surgery from memory.

On the first of two pages, which included everything up to 10:30 a.m., Verbrugge added a notation indicating he'd listened with a stethoscope after inserting the ET tube. On the second page, which was entirely blank, he wrote in levels of blood pressure, pulse, oxygen and carbon dioxide at five- to 15-minute intervals.

When he finished, he insisted that Nurse Garcia sign off on the first page, to verify it had been created during surgery. After some resistance, she initialed page one, but refused to sign page two.

Late that afternoon, two nurses drove Jay and China home. There, minutes later, the Leonards broke the news to their 10-year-old son, Ted, as he bounded up the front steps, fresh from his first Rockies baseball game.

Why did this happen? the Leonards cried to friends and relatives all through that long first evening of Richard's death. Shocked and disbelieving, they kept reliving the day, trying to change the ending.

Friends cried with them. Some blamed God, some senseless fate. Richard's friend Michael thought it all his fault, for he believed he'd caused Richard's ear problem. "I accidentally kicked his ear when we were climbing trees," he sobbed to his parents.

No, no, they explained to their son. Richard had suffered a rare reaction to the anesthesia, a 1-in-15,000 chance.

An enzyme reaction-that's what the Leonards repeatedly told friends and relatives in those early days. That was all they knew. That was all they'd been told at St. Joseph Hospital.

NEXT: The Leonards unearth the truth.

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Editor's Note: About This Story

The accounts in this story of Richard Leonard's operation, and of various meetings, conversations and reflections surrounding it, are drawn from numerous sources. They include sworn testimony at Dr. Joseph Verbrugge's disciplinary proceeding, the initial decision of the presiding administrative law judge, the final decision of the Colorado Board of Medical Examiners, exhibits and documents included in the proceeding's public record, reports from Dr. Verbrugge's psychiatrists, the deposition of Dr. Patrick McCallion, confirmations from St. Joseph Hospital lawyers and administrators, and direct interviews with many of those involved.

[Illustration]

PHOTO: COLOR, Above, Richard Leonard grabs for friend Michael Kalousek's cards as they celebrate Michael's 8th birthday. Right, Michael wears Richard's red jacket and keeps his bike, momentos of a friendship that ended too soon.; PHOTO: COLOR, Richard Leonard, 8, was undergoing minor ear surgery when he died at St. Joseph Hospital in Denver. / J. DALE SWENARTON; PHOTO: Dr. Joseph Verbrugge, charged with reckless manslaughter, turns himself in at a Denver police building. / GEORGE KOCHANIEC / Rocky Mountain News

Credit: TIMES STAFF WRITER

COLUMN ONE Boy's Death Cracks Shell of Privacy One doctor could not abide the way Richard Leonard died during surgery. He went after the anesthesiologist, and the medical world's code of confidentiality gave way to a case of manslaughter. Series: Medicine's Fatal Code of Silence. SECOND OF TWO PARTS; [Home Edition]

BARRY SIEGEL. Los Angeles Times (pre-1997 Fulltext). Los Angeles, Calif.: Aug 25, 1995. pg. 1

Abstract (Summary)

On July 8, 1993, Richard [Leonard] had died on an operating table during minor ear surgery at Denver's St. Joseph Hospital. Cardiac arrest due to potassium and carbon dioxide poisoning had been the immediate cause. Ever since, doctors, lawyers and administrators privately had been examining anesthesiologist Joseph Verbrugge's role in Richard's death. Charges of gross negligence had been leveled-charges that Richard died because Dr. Verbrugge failed to connect a crucial temperature probe, failed to monitor his patient's vital signs, failed to respond to his increasingly dire condition, failed to remain awake or alert during the surgery. Inside St. Joseph-one of Colorado's best hospitals-an investigatory committee had been formed, summary suspension of Verbrugge considered.

Six days after their son's death, the phone rang just as Jay and China Leonard were about to go out to dinner. They'd buried 8-year-old Richard the day before, with an organist playing the music from "Jurassic Park" for a gathering of 300 grieving friends and relatives. Then they'd come home, still railing at what they believed to be a senseless twist of fate.

On July 8, 1993, Richard had died on an operating table during minor ear surgery at Denver's St. Joseph Hospital. Cardiac arrest due to potassium and carbon dioxide poisoning had been the immediate cause. Ever since, doctors, lawyers and administrators privately had been examining anesthesiologist Joseph Verbrugge's role in Richard's death. Charges of gross negligence had been leveled-charges that Richard died because Dr. Verbrugge failed to connect a crucial temperature probe, failed to monitor his patient's vital signs, failed to respond to his increasingly dire condition, failed to remain awake or alert during the surgery. Inside St. Joseph-one of Colorado's best hospitals-an investigatory committee had been formed, summary suspension of Verbrugge considered.

Jay and China Leonard knew nothing of this, though. As they understood it, their son had died from a rare metabolic reaction to the anesthesia. That was all they'd been told, all they imagined.

On the phone now, Jay heard an unfamiliar man's voice. "Mr. Leonard," the voice advised, "I have strong reason to believe that what happened to your son was not an act of God. You should talk to your attorney."

It didn't sound like a crackpot to Jay.

"I expect you're not going to give me your name?" Jay responded.

The man hung up. Jay, shocked, sat holding the phone.

He considered himself reasonably sophisticated, a Ph.D. in geology with a thriving software business. All the same, he'd approached the medical system with his guard down. He'd believed Verbrugge when the shaken anesthesiologist, on the day of Richard's death, told him his son had died of a rare genetic condition called malignant hyperthermia, MH. Since then, he'd never believed otherwise.

He still didn't, even after this anonymous phone call. When reporters from the Denver Post and Rocky Mountain News called half an hour later, saying they were doing stories about Richard's death, Jay repeated what he'd been told at St. Joseph.

"An adverse enzyme reaction to the anesthesia," he earnestly told the reporters. "It causes your body temperature to rise."

The resulting articles the next day announced an "inquiry" into Richard's death but shed little light beyond Jay's words. Hospital spokeswoman Pat Riley would "say very little," the Rocky Mountain News wrote, citing "patient confidentiality." She "would not identify the physicians involved." But she did "want to express our most deepest sympathies to the family."

Alarms finally started ringing in Jay's mind when he read these articles. Why was there an inquiry, why was Richard's death on Page One? This metabolic condition called MH was a 1-in-15,000 occurrence. If this was something you usually died of, in a city the size of Denver, that meant there should be a death every-what?-2 1/2 weeks?

It didn't make sense. Jay decided to learn more. That weekend, he visited the University of Colorado medical school bookstore and bought anesthesiology textbooks. In one, he found a whole protocol about how to treat MH. If MH is detected early enough, it advised, chances of survival are almost 100%.

Jay stared at the words, reread them: "When MH is diagnosed early and treated promptly, the mortality rate should be near zero."

On Monday, Jay and China started interviewing lawyers.

Peer Review System

It wasn't entirely surprising that the Leonards went home from St. Joseph ignorant of what happened to their son. It wouldn't have been terribly extraordinary, for that matter, if the Leonards had never learned what happened in Operating Room 7.

A doctor's working life, after all, is largely free of external supervision or scrutiny. The profession is largely self-monitored by confidential hospital peer-review committees that face precise legal mandates and constraints.

Such private self-policing does have its advantages. Peer review protects patients, it is fairly argued, by encouraging everyone to speak openly and say what they think, without threat of exposure or punitive response or intrusion by lawyers. If you violate confidentiality, it's been shown, many won't come forward, problems won't be revealed.

Peer review, however, doesn't always work as well in practice as in theory. Doctors often resist identifying incompetent colleagues for fear of lawsuits and reprisals. They know who the few bad doctors are but shrink from the hassle of confrontation.

A 1991 Harvard University study of deaths in 51 New York state hospitals, when extrapolated to the country at large, indicates 80,000 deaths each year are due to doctors' mistakes. Yet only 2,000 doctors are disciplined each year by state medical boards. Many more presumably draw some sanctions, but they remain wrapped in the confidentiality of internal peer review.

To better monitor this situation nationwide, the federal government in 1990 opened the National Practitioner Data Bank, a computerized database that keeps records on license revocations, restricted hospital privileges, malpractice judgments and other disciplinary actions. It's accessible only to hospitals, though, not individual doctors or the public. What's more, it's not overly comprehensive. The first year in operation, the data bank received only 750 reports; the second, 1,000.

Problem doctors sometimes avoid database entry by resigning from hospitals before peer review investigations begin. Hospitals sometimes impose 29-day suspensions, thus avoiding the requirement to report suspensions of 30 days or more. Not infrequently, hospitals simply push problem doctors out the door without formal charges; the hospital avoids a messy situation, while the doctor goes off to practice elsewhere with an untarnished record.

In the initial hours after Richard's death, it is possible to see hints that such familiar veils of privacy were descending. If they were, though, they didn't make it all the way down.

Although Jay and China Leonard didn't know it then, the mysterious phone call they received the day after Richard's funeral was an early sign of an uncommon uprising within the medical community.

As chief of anesthesia for Kaiser's Colorado Permanente Medical Group, Dr. Michael Leonard (no relation to Jay and China) felt a sense of responsibility for what had happened to Richard. Jay and China were enrolled in Kaiser, but with its own staff fully booked, Kaiser had arranged for an independent group of doctors to provide an anesthesiologist for Richard's operation. That group had assigned Verbrugge.

So on the evening of Richard's death, Mike Leonard began to investigate. That night, he spoke by phone with two Kaiser anesthesiologists who'd initially responded to the code when Richard's heart arrested. At 8:30 the next morning, he met with nurse Delia Garcia, who'd spent some time in the operating room during Richard's attempted resuscitation.

Then the hospital clamped down.

According to Mike Leonard, St. Joseph in effect "sequestered" nurses Mary Kay Harrell and Karen Latson, who'd attended at Richard's operation. Don't talk to Dr. Leonard or anyone from Kaiser, he says a risk management officer instructed the nurses. If you do, you'll be fired.

It was a typical response from a hospital in this situation, and at least from a lawyer's point of view, a correct one. No hospital attorney wants witnesses making comments that could compromise the integrity of the procedure-that could open the door to civil court challenges. The nurses weren't told only to avoid Kaiser, a St. Joseph lawyer explains; they were told not to talk to anyone.

The response nonetheless disturbed Mike Leonard.

To protest, he called Dr. Tray Styler, chairman of St. Joseph's anesthesia department. He related what he understood at that time about Verbrugge's responsibility for Richard's death. He also expressed concern about the nurses' sequestration. Styler acknowledged that he'd heard the same complaints and was in the process of investigating them.

Later that morning, Mike Leonard and his Kaiser supervisor met with St. Joseph medical director Dr. Bruce Jensen. "Essentially in that meeting we were informed, because of the need for confidentiality, that they preferred to investigate the matter themselves," Dr. Leonard testified at the subsequent hearing into Richard's death.

As he understood it, the hospital would be convening an investigatory committee shortly and would be meeting that afternoon to decide whether to summarily suspend Verbrugge. But Dr. Leonard wasn't comfortable with letting St. Joseph's internal process run its course. What with reports, hearings and challenges, such proceedings sometimes took months, even longer.

Then 41, Dr. Leonard was considered by colleagues a deliberate and restrained man, devoted to his young children, partial to mountain-climbing and skiing. He'd studied at the University of Missouri, then done his internship and residency at Beth Israel Hospital-Harvard Medical School, before coming to Denver in early 1988.

He thought long and hard about what next to do.

The cardinal feature of anesthesia, he believed, was to be vigilant. You take somebody's life in your hands and put him to sleep, you have a tremendous obligation to care for him. If you don't feel you can do it, you don't go into the O.R. that day. Verbrugge's unresponsive conduct personally offended him; he also had serious concerns about this doctor's safety.

On Sunday, July 11, three days after Richard's death, Leonard typed a three-page, single-spaced letter to the Colorado State Board of Medical Examiners. "Please find enclosed information concerning the recent death of an 8-year-old boy during relatively minor surgery at St. Joseph Hospital," he began. "Given the extremely serious nature and totally unacceptable level of care delivered in this case, I felt morally obligated to bring this matter to your attention rapidly."

At this early date, Leonard had some of the details and issues wrong, but in his fundamental conclusions, he foreshadowed what a judge and the medical board months later would conclude: "A major failure of vigilance and observation on the part of this anesthesiologist is a virtual certainty . . . ," he wrote. "It is absolutely clear that an appalling level of neglect and substandard anesthetic care in this case caused the death of this innocent child."

Leonard delivered his letter to the board on Monday morning. By Wednesday, it was in the hands of Robert Spencer, an assistant state attorney general.

As counsel to the board's investigatory and prosecuting arm, Spencer usually hears about doctors' transgressions through malpractice settlements, or from hospitals after a sometimes lengthy peer review process. He wasn't accustomed to getting a letter such as Leonard's. Although by law it was obligated, it was highly unusual for a doctor actually to speak out in this manner.

"Wow!" Spencer thought as he read Leonard's words. This is pretty strong.

Only rarely, maybe six times a year in Colorado, did the board summarily suspend a doctor before a hearing. This situation, Spencer thought, suggested such a course.

Before acting, though, Spencer wanted to assess the person who'd written the letter, to make sure Leonard was reliable. When they met, Spencer found him considered, unassuming, reasonable. Here, he decided, was a horse who would cross the stream with them.

Typically, the Board of Medical Examiners would let the hospital suspend Verbrugge and conduct its own peer review before it stepped in months later. But Leonard's involvement now greatly accelerated the process. Accelerated it-and also altered its outcome.

Medicine is so much a matter of subjective judgment, after all, and so much a mystery to lay persons. By speaking out, by providing his authority, Leonard gave Spencer and others the foundation to act.

"I might not have been as sure about this case without Leonard," Spencer observed later. "Once I met and spoke with Leonard, I was convinced this was a very serious case."

The assistant attorney general was so impressed at their first meeting, he wanted Mike Leonard not just as his whistle-blower but also as his expert witness.

The doctor readily agreed.

You'll be on the spot, Spencer warned. The defense will try to impeach you, to attack your motives and knowledge.

Mike Leonard didn't hesitate. "That's part of being a citizen in the medical community," he told Spencer.

Cracking the Case

Jay and China were stunned when they finally began to grasp what had happened to their son in St. Joseph's Operating Room 7.

Their education, sparked by Jay's reading of anesthesia textbooks, accelerated when Assistant Atty. Gen. Spencer filed a formal complaint against Verbrugge one month after Richard's death. Spencer had found no proof of substance abuse-Verbrugge had requested a drug test immediately after Richard's death, and tested negative. But with St. Joseph's investigatory file, Mike Leonard's analysis and his own interviews in hand, Spencer had pieced together a story that fairly shouted gross negligence.

Jay and China still didn't know about Verbrugge's troubled background, though. Nor did Bob Spencer. Because of peer review confidentiality, no one at St. Joseph had shared the fact that Verbrugge's record included a number of incidents of abrasive or inattentive behavior during operations, including half a dozen times where colleagues believed he'd fallen asleep. Publicly, St. Joseph still had "no comment" about the charges against Verbrugge.

In the late fall of 1993, seeking to buttress his case, Spencer finally asked St. Joseph if there was a peer review file on Verbrugge. As lawyer for the board of examiners, he had a right to see it.

Yes there was, came the reply.

Can I have it? Spencer asked.

Please subpoena it, the hospital said.

To Spencer, St. Joseph wasn't being uncooperative; this was just how the process played itself out.

When he opened Verbrugge's file, Spencer's eyes widened.

It contained actions against Verbrugge that weren't reportable, for otherwise the Board of Medical Examiners would already have heard of them. Still, Spencer observed later, "there's lots of good peer review action that can be done before the reportable level."

Jay and China hardly knew how to feel when Spencer, in December, 1993, amended his complaint to charge Verbrugge, on six specific dates from 1990 to 1993, with failing "to remain awake and otherwise alert and vigilant" during surgery. They felt even more unsettled a month later, when Spencer briefed them about what they'd hear at Verbrugge's coming disciplinary proceeding. For the first time, Jay and China learned of Dr. Michael Leonard's critical role.

By and large, they still believed very few doctors were bad. But they were staggered by the tremendous resources summoned to protect those few who were. In other fields, you'd just weed them out. Why were the doctors so clubby? It happens in all fields, people go bad. You flush them out.

Believing they could do just that, the Leonards began to campaign actively on several fronts. They urged that Verbrugge's license be revoked. They raised questions about a possible criminal prosecution. They laid plans to organize and finance a private national database on problem doctors.

For a while, it looked as if the Leonards could achieve both solace and reform.

Midway through the state's nine-day disciplinary proceeding against Verbrugge in February, 1994, Jay and China watched Mike Leonard convincingly dismiss the basic dispute over Richard's death. Had he died of MH, or because an undetected mucous plug blocked his exhalation of carbon dioxide? It didn't matter, Leonard contended; either way, it was the lack of response that killed Richard. "If I may make a little personal statement here," he said, "I think we spent a lot of time talking about technicalities . . . . The fundamental issue for me is the 30-to-45 minute period of complete negligence during which this child got into trouble . . . ."

At the proceeding's conclusion, Jay and China watched Mike Leonard unequivocally declare Verbrugge "not safe to practice anesthesia . . . . I believe the care in this case was so abhorrent I would be very hard-pressed to recommend that this gentleman get the opportunity to do this again."

In May, 1994, they watched Administrative Law Judge Judith Schulman, who presided at the hearing, embrace Mike Leonard's analysis utterly. They watched her find in Verbrugge's record multiple instances of "substandard" and "grossly negligent" conduct and conclude that Verbrugge's "lack of vigilance in all likelihood directly resulted in (Richard's) death."

Last December, they watched the Colorado State Board of Medical Examiners uphold Schulman's every finding and strip Verbrugge of his license.

Finally, in April, they watched the Denver district attorney's office file reckless manslaughter charges against Verbrugge. What happened in Operating Room 7 was not just a bad mistake or even gross negligence, declared Chief Deputy Dist. Atty. Diane Balkin. What happened was conscious disregard for a person's life.

The Leonards had witnessed all they'd hoped for. To their surprise, though, it didn't provide what they'd expected. They'd imagined feeling good once the proceedings were over, once Verbrugge's license was revoked. Instead, they felt hollow.

Solace was still beyond their reach. So, it would prove, was reform.

Growing Scrutiny

Criminal prosecutions against doctors for their professional conduct are extremely rare, but they've recently become a little less so.

In March in New York, a physician was convicted of reckless endangerment in connection with the death of an elderly nursing home patient. In April, the Milwaukee district attorney brought reckless homicide charges against a medical laboratory accused of misreading the Pap smears of two women who later died of cervical cancer. Two weeks ago, a New York City obstetrician was convicted of second-degree murder in the death of a woman after an abortion.

These, combined with Verbrugge's prosecution, have greatly alarmed much of the medical profession. Talk abounds about trends and implications-a diminished trust in doctors because of "marketplace medicine," an atmosphere that convinces prosecutors they can make criminal charges stick. The American Medical Assn. has been inundated with letters from agitated, scared doctors.

Criminal prosecutions, doctors' groups contend, will "irreparably chill" the practice of medicine. That, in fact, was precisely what Verbrugge said one day recently, talking in his lawyer's office.

His manner a combination of geniality and bluster, Verbrugge blamed his problems mainly on his irascible treatment of nurses. He should have connected the temperature probe and he should have diagnosed MH quicker, he allowed, but these were errors, not intentional acts.

"If we have to run scared of criminal prosecution every time we treat a patient," Verbrugge said, "that carries a lot of implications. Especially if the definition of criminal steps over the boundaries of professional malpractice. Doctors are human. I'm human. In malpractice suits, you admit to mistakes. But is that criminal?"

There are many who believe the general themes sounded by Verbrugge have some merit, even if they don't fit well with the details of his particular case. There are no distinct lines separating malpractice from manslaughter, after all. It's a subjective judgment that derives as much from community values and visceral instincts as from the law. "I can't articulate why we filed," Deputy D.A. Balkin said recently. "Decisions are made."

No doubt this vulnerability to the D.A.'s discretion is one reason Verbrugge's criminal prosecution has roiled the Denver medical community and turned a good number of doctors against the Leonard family. Some perceive Jay and China as having inspired and lobbied for the prosecution; some have helped pay Verbrugge's legal fees. Even their own family doctors have acted coolly, Jay Leonard says. "They feel we are going too far. They say they're scared at the prospect of being charged as criminals for making mistakes."

Fueled by such concerns, the story of Richard Leonard's death has now evolved into a familiar courtroom skirmish full of wily lawyers, ingenious motions and artful strategies. In a realm where so much is shaded and subjective, everyone is maneuvering for favorable position. Even St. Joseph Hospital has finally ventured beyond its veil of legally mandated confidentiality, albeit reluctantly and cautiously.

"I just wish this would go away," sighed Judith Swanson, the hospital's vice president for planning and marketing, as she arranged for a reporter's visit. When the hospital's president, Sister Marianna Bauder, appeared for a brief interview, she did so with a hospital lawyer at her side, and a tape recorder.

She talked of how "terribly unfortunate, terribly sad" Richard's death was. She talked about St. Joseph's quality assurance and re-credentialing process. She wondered how you go beyond "counseling and admonishing" a doctor who's never had a "bad outcome" in years of practice, when doing so requires reporting him to boards and data banks.

The hospital cooperated, responded, conducted its own investigation, Sister Bauder pointed out. The hospital made changes-a temperature probe is now required, anesthesiologists must chart more frequently, Verbrugge will never practice there again.

Peer review remains as is, though. Peer review protects patients by allowing all to speak openly. Peer review has worked well over St. Joseph's 122 years. You should not judge the system by one bad case.

In the end, Sister Bauder said, she just "was not sure" what they could have done differently.

Sister Bauder isn't alone. The larger question of peer review policing, ambiguous by nature and much influenced by powerful political lobbies, will not likely find resolution in the aftermath of Richard Leonard's death. Culpability for what happened in Operating Room 7 certainly will remain focused narrowly on Joseph Verbrugge.

It is no one's job, after all, to point fingers elsewhere. Broader accountability is a "difficult question," observe some of those who have pursued Verbrugge. How to deal with a troubled professional? That's hard for a hospital, they say. That's hard for the medical community.

It is this attitude, finally, that leaves Jay and China Leonard still so disturbed two years after Richard's death. Amid all the compassion and intellect in the medical community, they ask, where is the moral courage?

Verbrugge was an accident waiting to happen, Jay and China suggest. Why hadn't St. Joseph somehow stopped Verbrugge well before Richard's operation?

What about the surgeon and two nurses in Operating Room 7? It's hard to believe they stood by and didn't intervene. Richard's temperature was 108 when he died. Those nurses-why didn't they grab Verbrugge's lapels, yell "Wake up"? Why didn't they tell the surgeon? Why didn't the surgeon take charge? They must feel guilt, they must feel regret.

What of Verbrugge's colleagues and partners? If Verbrugge couldn't recognize his own problems, someone else was obliged to do so for him. If doctors don't want lawyers and criminal prosecutions, then they must police their own. They must take responsibility.

"Not peer review, lawyers, litigation, hearings," Jay Leonard said recently. "I'm talking his partners, his colleagues. They must pull him aside, say, `You've got problems.' It's not punitive; that's not the issue. There's the legal system, there's the administrative system, then there's the human system. It's the human system that really failed in this case."

The Leonards have memorialized Richard with a display in his honor at the city zoo he loved so much and with an annual award at his school. They push on with plans to launch a national database of problem doctors. They consult regularly with the district attorney's office about Verbrugge's prosecution. A preliminary hearing is scheduled for next month; the trial will likely begin near the end of the year.

Jay and China still long for closure, though, without knowing quite what it requires. They've even tried reading about an afterlife. Nothing has worked.

"It doesn't change anything," China said. "Richard is still dead."

Richard is still dead, and the medical system still polices and licenses as usual. It's for this reason, no doubt, that Joseph Verbrugge in March, 1994, a month after his censorious disciplinary hearing, felt free to apply for a medical license in New Mexico. It's also for this reason that Jay Leonard, learning of the application, found himself obliged in February to write the New Mexico board-to send them documents, to tell his story, to urge a denial.

It is likely the Leonards will prevail; it is likely New Mexico will pay heed to Verbrugge's record. License revocations in one state, however, don't automatically preclude licensing in another state.

Each case is looked at individually by the New Mexico board, its executive secretary remarked recently. That can take a year or more to be decided. As of July, she reported, Verbrugge's application was still pending. It was on a back burner, probably awaiting final action in Colorado. Confidentiality, she explained, prevented her from saying more.

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Editor's Note: About This Story

[Illustration]

PHOTO: COLOR, Jay and China Leonard, with their son Ted, find little solace in the prosecution. "It doesn't change anything. Richard is still dead," China says. / ELLEN JASKOL / For The Times; PHOTO: COLOR, Diane Balkin, chief deputy district attorney, filed reckless manslaughter charges against the anesthesiologist in Richard Leonard's death. / ELLEN JASKOL / For The Times; PHOTO: COLOR, Dr. Joseph Verbrugge, left, at the Denver police building, has lost his license to practice in Colorado but could be licensed in another state. / GEORGE KOCHANIEC JR. / Rocky Mountain News; PHOTO: Richard Leonard plays with his friend's family dog three days before the 8-year-old boy went into surgery at Denver's St. Joseph Hospital.

Credit: TIMES STAFF WRITER

Boy's death cracks shell of privacy

Siegel, Barry. Los Angeles Times. Los Angeles, Calif.: Aug 25, 1995. pg. A1

Abstract (Summary)

The death of eight-year-old Richard Leonard in Denver following a routine ear surgery led to an internal probe of the attending anesthesiologist, Joseph Verbrugge. The case has led to charges of manslaughter against Verbrugge.

Los Angeles, Calif.: Los Angeles Times pg. 8

Abstract (Summary)

Re "Medicine's Fatal Code of Silence," Aug. 24: Not only does it seem that the anesthesiologist is criminally negligent, but every member of the operating room team should share responsibility for 8-year-old Richard Leonard's death.

Twenty years ago I worked in a surgical intensive care unit for burn victims. We had a standard set of procedures that everyone had to follow, from the chief of plastic surgery to the lowliest technician. Each burn team member took personal responsibility for assessing the care and the changing status of each patient.

Standard procedures ought to be published, checked and rechecked out loud and regularly. No one's personality or bad day should ever jeopardize the safety or health of any patient.

TIM REGAN

Los Angeles

The article strikes an all too familiar chord--the lack of moral responsibility, not only in the medical community, but in the human community. It is the same lack of moral obligation in a society where people stand around and witnesses a woman being beaten and then plunging to her death off a bridge in Detroit.

The Leonard family, due to their actions, were victorious in getting the doctor's license revoked. However, those who worked beside Joseph Verbrugge in Operating Room 7 should also be held to the same level of accountability due to their lack of intervention well before the unconscionable events that took an innocent boy's life.

VICKI L. GLICHER

Northridge

As an experienced OR nurse and supervisor I can assure you this is not an unusual set of circumstances.

My 20-plus years were filled with frustration in attempting to protect the patient from just such incidents. Documentation of and reporting of incidents such as ghost surgery, incompetent physicians, falsification of charts were to no avail. The only recourse I as supervisor had was to remove my nurses from a room so the surgery could not take place or develop a unique charting method that could be used in court. Sad but true.

RUTH I. HARMON

Santa Ana

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