Question

A Sudden Pain

One Monday morning in early 2004 my husband Jerry woke me and said his back was hurting. When the pain became severe we decided to go to the emergency room. At the emergency room, they treated him for the pain with several rounds of narcotics, including injections of morphine and Dilaudid. The emergency room doctor arrived and ordered a CT scan. When the CT scan results came back, the emergency room physician said that it looked as though Jerry was passing a kidney stone. Jerry was admitted to the medical-surgical unit for observation and pain management.

The hospital suggested a urologist, who v

visited us that afternoon. The urologist confirmed that there was a kidney stone but said the CT scan also had shown a small mass within the kidney. He wanted to do an additional test, with dye, to see the mass.

Jerry was given morphine and the painkiller Toradol (ketorolac) by intravenous injection every 4 hours through the night and into the following day. They also set up IV fluids to help wash out the kidney stone.

The next morning, Tuesday, Jerry was supposed to have a CT scan with dye to get a better look at the mass in his kidney. I went to school to prepare lesson plans in anticipation of being away from class. When I returned to the hospital, Jerry told me that they had not done the test because something was wrong. So I found a nurse, who said that Jerry’s blood work had shown his serum creatinine level was rising. They did not want to perform the dye test until these kidney function test results looked better.

Jerry continued to receive Toradol throughout the day even though his pain was well controlled. I asked a nurse if this kind of high creatinine level was normal for a person with a kidney stone. She told me that it was probably caused by the Toradol and explained that nonsteroidal anti-inflammatory drugs like Toradol can cause the creatinine level to rise. She told me Jerry was getting too much Toradol.

This nurse was an RN—a registered nurse—but I did not realize this at the time. The nurses’ badges did not designate whether they were an RN or a licensed vocational nurse (LVN). The attire was the same for all nurses, so I could not distinguish between them. The hospital’s policy was to use RNs only as “resource” nurses. There were only two registered nurses on the floor, and they were not assigned to specific patients. The bedside nurses taking care of the patients were LVNs. So if an LVN needed to give a medication that she was not authorized to give, the LVN had to find a registered nurse who could administer the medication. I did not understand at the time that this was the policy.

When the doctor came to the room on Tuesday evening around 5:30, I mentioned Jerry’s creatinine level and told him what the nurse had said. While the doctor was in the room his three pagers went off at various times, all while we were trying to have a conversation about Jerry. When I brought up the creatinine a second time, he told us he would discontinue the Toradol and restart the IV fluids to get the creatinine level down.

By 7:00 that night they still had not started the IV fluids. When the night shift nurse came in, she told me there had been no order placed for this request. At my insistence, she called the doctor, and later she started the IV and discontinued the Toradol. At that time, Jerry’s pain medication was changed to a Lortab tablet every 4 hours because his pain level was now only about 2 on a scale of 1–10.

On Wednesday morning I dropped by the hospital and then I went on to school. Around noon Jerry called and asked me to come back to the hospital. He said they were trying to explain something to him but he could not understand because the medication was making him feel confused. So I arranged for a substitute teacher for the afternoon and returned to the hospital.

I stayed with Jerry throughout the evening. About 7:15 that evening the bedside nurse (an LVN) came in with medication. Jerry told her he was not going to take it because it was making him feel odd and his pain level was minimal. The LVN told him that he needed to maintain his pain relief regimen, but Jerry refused the Lortab. He told her that if he needed the medication he would let her know. I left the hospital about 8:00 that evening, as our son Jordan had come to visit Jerry. They watched basketball and talked politics until around 9:00 p.m., when Jordan left the hospital.

Jerry was set to go home the next morning. We were just waiting for results of the morning blood test to confirm that his creatinine level had come down so that he could be discharged. Because the CT scan with dye had not been done, Jerry was scheduled for an MRI after discharge because the hospital did not offer open MRI services. His pain was minimal and manageable with Lortab, so the doctor had told Jerry he could leave the hospital to get the MRI and follow up after the doctor’s office had received the images.

Your Husband Is Dead

The following morning, Thursday, January 22, the phone rang at 5:50 a.m. I thought it must be Jerry because when he was away from home he would often call early in the morning to say good morning. The person on the phone told me that my husband had had an emergency and that I needed to come to the hospital immediately. When I asked what had happened, she said there had been an emergency and a urologist was in with him now. She asked how long it would take me to get to the hospital. I said about 5 minutes. I was terrified. She had given me no information about my husband’s “emergency.” I assumed because a urologist was with him that he was passing the kidney stone and that something had happened related to the kidney stone.

I dashed to the hospital and ran up to the second floor where Jerry’s room was. As I entered the waiting area I saw our son. At that moment my heart stopped. A nurse I had never seen before came walking toward me as I started down the hall to Jerry’s room; she took Jordan and me into an empty patient room. The nurse looked at me and said, “Your husband is dead.” I was absolutely stunned. This could not be true. I kept repeating, “No! No!”

A young woman who was standing with the nurse told us that pain medication had been given to Jerry sometime in the early morning hours. She was crying as she told us this. I learned later that she was the new on-call attending physician for the urology group. She had only recently finished her residency. She had never seen Jerry before but had been called to the hospital when the staff discovered that Jerry was dead.

The nurse repeated to me several times, “Your husband died peacefully in his sleep. You can take comfort in that.” At that point, I ran out of that room and into Jerry’s room, and he did look asleep, except that there were tubes inserted into his mouth and I saw a catheter hanging on his bed. The room was nice and neat, and Jerry was lying on his back with his hands on his chest. It all looked surreal.

My shock was so complete that I tried to wake Jerry—tried shaking him—finally collapsing in screams and sobs. The same nurse stood in the doorway and said again, “He looks like he is just sleeping, doesn’t he? Doesn’t he look peaceful?”

The young doctor who had told us about Jerry’s death was gone. I asked again and again what had happened, but we could not get anyone to answer any specific questions. When I asked about the tubing and the catheter, the nurse said they had called a code and that a full resuscitation with intubation was standard procedure. A nurse came into the room some time later and asked if we wanted the tubes removed. I said, “No, don’t change anything.” I did not want anything changed because I did not know what had happened.

During that morning I questioned nurses and the administrator who had come in to talk to us. I kept receiving the same news—that Jerry had died peacefully in his sleep. The administrator asked us about funeral arrangements, and a nurse brought in a release form. I asked about the county medical examiner. Had he been called? When would someone come to begin the investigation? The nurse told me that the medical examiner’s office was “not interested in investigating” Jerry’s death. I was stunned. I asked, “What did you tell them about the cause of his death?”

She replied, “Renal failure.”

Again, I was shocked. I knew for certain that his death was not caused by renal failure. Just a few hours ago, Jerry had been in minimal pain, talking, laughing, and watching basketball. There had never been any mention of renal failure. We later learned that the Harris County medical examiner’s office had no record of a call from the hospital about Jerry’s death. A representative from that office gave a sworn affidavit attesting to “no record of a call concerning Jerry Carswell” received from the hospital.

I told the hospital administrator that I wanted an autopsy. Jerry was supposed to come home, he had no other health problems, he was taking no other medications, and he had been active. The nurse told me that the urologist had already ordered an autopsy. I asked how that worked. Did they do them here or somewhere else? The nurse said they would do the autopsy at a hospital in downtown Houston. I told her that I did not want the hospital where Jerry had died to perform the autopsy, because I wanted an independent autopsy. The nurse replied that an autopsy could cost up to $10,000. At this point I did not care how much it might cost; I just wanted it to be complete so I could find out what had happened. Jordan and I talked this over—we wanted an autopsy that would tell us why Jerry had died.

A nurse brought me the document to request the autopsy. She assured me that the autopsy conducted by the hospital would be “just like” an autopsy I would get from an independent pathologist. There was a place to mark if I wanted a partial autopsy or anything specific. I wrote on the paper, “Complete Autopsy,” and signed it.

At one point the hospital administrator came into the room and announced that it was “time for us to go home.” I told her I wanted to be there when the funeral home transported Jerry’s body out of the hospital. I again stated that I did not want anything removed from Jerry’s body, and I specifically requested that the urine from the catheter bag go to the autopsy. Later, around noon, the administrator came back in and told us the funeral home was on their way to transport Jerry’s body for autopsy. She literally placed her hand on my back and pushed me toward the door of the room. We all then left the hospital and went home. Later, I learned that the funeral home did not arrive at the hospital until more than an hour later.

There are no adequate words to describe what I felt like leaving the hospital, the reality of the cold air when I got outside, of what had just happened inside that building. Jerry was gone. I could not absorb that fact, or that I had just signed for an autopsy when I had never before had any occasion even to think about an autopsy, or the fact that no one at the hospital would tell us anything specific about how Jerry died. There I was, going back home alone—this surely was some terrible nightmare.

Looking for Answers

When I went home, I called friends, and they called friends, and by the next day the Houston Chronicle published a story in the sports section about the loss of this man whom everyone in the area knew. There was an outpouring of response from coaches in the area and from the students Jerry had coached. His death was a great loss to many people.

While we were mourning his loss, Jerry’s body was being transferred to the pathology lab at the hospital in Houston. The autopsy was done there. But it turned out that this hospital was a sister hospital to the one where Jerry had died. It was not the independent autopsy we thought we were getting.

We later found that there are two distinct kinds of autopsy procedures. Clinical autopsies, the kind usually done in hospitals, do not include the same investigative procedures that a forensic autopsy does. Even though a large dose of narcotics had been administered to Jerry prior to his death, Jerry’s autopsy did not include toxicology screening that would have been done by the medical examiner or by an independent pathologist in what is called a forensic autopsy. Jerry’s autopsy was done by a pathologist who testified that he had never done a toxicology screen in an autopsy, not once in his 20+ years of working for that hospital pathology group. The pathologist did not test the urine that remained in the body. The urine bag that I had seen in the hospital room disappeared. A hospital pathologist said the bag was not with the body when it arrived in the lab.

Shortly after Jerry was buried, I went to the hospital and got his records. When I read the report from the emergency room doctor who had been called to the code, it said that Jerry had been found lying across the bottom of the bed as if he had been trying to get up. The urologist’s report said the same thing. This was in direct conflict with what I had been told at the hospital, that he had “died peacefully” in his sleep.

That is the point at which I decided I needed more information. The attending urologist from the hospital helped us get the autopsy report, but he never answered my questions about why there were two conflicting stories. The hospital did not return my calls.

When we received the death certificate, there was no cause of death listed. We still, even now, do not have an official cause of death. The death certificate listed three conditions present prior to death. These had to do with an irritation in the lining of Jerry’s stomach and in the pyloric area, both of which we believe were probably side effects of the Toradol and not underlying conditions; Jerry had no indication of any kind of medical distress other than the kidney stone until we came to the hospital. Ironically, the autopsy report showed no kidney stone on the right side where Jerry’s pain had been. It noted a small stone on the other side still in the kidney. It also noted the small mass and said it “appears confined to the kidney.”

After seeing Jerry’s medical records, I talked with a friend who encouraged me to contact an attorney to see if we could find out what had caused Jerry’s sudden and unexpected death. We then entered a long and difficult legal process that I wish we had not had to do. In that process we discovered a number of issues that were very disturbing.

One key issue was that the amount of the medication Toradol that Jerry had been given was far in excess of the strict limits recommended for this drug. This explained why the drug had such an adverse effect on his kidneys. Another was that the LVN who was administering the Toradol was not allowed by hospital policy to administer this class of drug and did not have sufficient training in the purpose of the drug or its possible side effects, which include adverse effects on the kidneys. Because the RNs were floaters and were not assigned to specific patients, there was no real monitoring or oversight of the bedside LVN nurses.

We also discovered that just before midnight on the night Jerry died, the same LVN had written details in Jerry’s chart about giving pain medication to a knee surgery patient. She had detailed the angle the knee was positioned in and things like that. By the time we saw the records, this information had been lined out. The correction was initialed and dated January 22, the morning of Jerry’s death, indicating to us that Jerry’s LVN had not noticed her mistake during the night that Jerry died. Personnel records showed that this LVN had taken many extra shifts that week—more than twice the hours of any other nurse. I am not sure what mental state she was in the night of Jerry’s death, but she definitely placed the wrong information in Jerry’s record. As part of the correction done after Jerry’s death, she reported that she had administered Lortab to Jerry about 1:00 a.m. We wondered if she could have given him the Lortab and the surgery patient’s medication, too.

Jerry’s records reflect a call to the on-call urologist saying that Jerry had been in level 9–10 pain since 1:00 a.m. At 3:15 a.m., according to the medication record, a nurse—it is unclear which nurse—administered a bolus does of 75 mg of Demerol and 25 mg of Phenergan. In trial, a laboratory technician stated she encountered two nurses coming out of Jerry’s room with a syringe at 5:00 a.m. There is no record of a 5:00 a.m. medication administration, however. When the lab tech entered the room around 5:15 a.m. to draw blood, she found Jerry’s lifeless body.

It was a year before we sought legal recourse, but in the end we felt we had no choice. The legal process was slow and stalled repeatedly for various reasons, including changes in hospital ownership. The hospital was uncooperative, and the judge sanctioned them for spoliation and destruction of evidence. The hospital mounted an unsuccessful challenge against both the sanctions and our requests for evidence. Then the hospital where the autopsy had been done filed for bankruptcy. All told, it took us 5 and a half years to get into a courtroom. When we finally got there, the hospital administrator and nurses denied under oath that they had ever spoken to Jordan and me about the funeral home or the autopsy. This was proven not true by funeral home documents and by the testimony of other people who had been present that morning.

The jury vote fell two votes short of the number required for a negligence verdict in Texas. Several jurors later stated to my attorney that because there was no official cause of death, they felt there were too many unanswered questions to make a determination, even though they felt that the hospital had caused Jerry’s unexpected death. The jury voted in our favor on the post-mortem fraud, finding that the statements hospital personnel made to me had led me to believe the autopsy would be “complete” and would be an investigation into the cause of Jerry’s death. In a unanimous vote, the jury added punitive damages as a punishment for what they considered the hospital’s egregious misconduct.

Conclusion

One of the most shocking things to come out of the lawsuit occurred during the pathologist’s deposition. He stated that he had removed Jerry’s “whole heart” and retained it in his lab. The pathologist did not request permission or inform me that he had retained Jerry’s heart and stored it in an unmarked plastic bucket in the pathology lab. We had buried Jerry without his heart, a disturbing and painful realization that haunts us still.

I became convinced that Texas needed a state-promulgated consent form for autopsy so that families could be informed about their rights concerning autopsies. In addition to Jerry’s heart being removed without our knowledge, Jerry’s death met three of the six conditions that Texas law specifies as requiring a death investigation or forensic autopsy. I went to my state representative and asked him to sponsor a bill that would require hospitals to use an “informed consent” for autopsy, a document that would inform families of their legal rights. The Jerry Carswell Memorial Act passed the Texas legislature in 2011, and now every medical institution in the state must use this form when they ask for permission to do an autopsy. The form lists the conditions under which state law says there must be a death investigation and states that the patient’s family has the right to request an independent pathologist to attend or perform the autopsy (Figure 15-1).

Questions

What do you think Jerry Carswell’s nurses and doctors could have done to protect against the adverse outcome that occurred?

What steps do you think the hospital should have taken to avoid the suspicions and antagonisms that immediately arose between this family and the hospital?

Consider the legal process in this lengthy case from both the hospital’s and the family’s point of view. Is this the best way to handle this situation?

Should more autopsies be mandated? Read some of the literature on autopsy findings and discuss whether you think a high autopsy rate is a good idea.

Look up the differences between forensic and clinical autopsies. Should toxicology screening be required in hospital autopsies?

Which of the core competencies for health professions are most relevant for this case ?why?

Answer 1

Hospital covered the case with renal failure for protecting against the adverse outcome that occured,Because jerry's wife know that his death not because of renal failure,he had only kidney stone and small mass in his kidney..
? Nurses and doctors told so many times 'your husband died peacefully in his sleep'.They inserted catheter in his mouth and they did resuscitation with intubation..after death they wanted to remove the tubes without proper evidence..so jerry's wife tols not to change anything unless investigation done by medical examiner's office..but medical examiner's office rejected to do the investigation and said not interested.
? Yes this the best way to handle this situation..because the hospital was incooperative,and the judge sanctioned them for spoliation and destruction of evidence.Then the hospital were the autopsy had been done filled for bankruptcy..The hospital mounted an unsuccessful challenge against both the sactions and our requests for evidence..
? Inthis case only two autopsy were mentioned that is clinical and forensic autopsy..The pathologist he did not do the urine test because it was absent..but in this high autopsy rate is needed..because in hospital they did the post-mortem fraud..they would have done anatomical autopsy also..
? There are two distinct kinds of autopsy parocedure ..in this case only 2 autopsies were mentioned that is forensic and clinical autopsy..In forensic biopsy they used to determine the cause and manner of death and it involve the application of the sciences to answer questions of interest to the legal system...In clinical autopsy serve two major purpose..it is done to perform with more pathological process and determine the factors towards patients death..it will be done in hospital.. hospital autopsy must include the toxicology report also..because LVN had given a wrong medication with extra dosage..
? Because most shocking thing was jerry's heart had stolen and it was stored in unmarked plastic bucket In the pathology lab..It was done by health professions..
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