Tinker Ready

In North Carolina, fatal medical ‘misadventures’ kept under wraps

clip misadventures (2).JPGStaff writers

July 16, 1995, A1

The News & Observer, Raleigh, NC

Arthur Kirby Moore, a real estate executive from Greensboro, was in good shape for a 68-year-old man. On June 16, 1991, he played a terrific round of golf and scored his age.

On June 17, he died.

Moore was killed by a doctor’s error during throat surgery at a Greensboro hospital, according to an autopsy report at the state’s chief medical examiner’s office. He suffocated when an ear, nose and throat specialist sewed a piece of tissue over his larynx by mistake.

“This poor man went into the hospital for outpatient day surgery and he died,” said his son, Alan L. Moore of Winston-Salem.

Fatal medical mistakes like the one that killed Kirby Moore happen at least twice a month in North Carolina, according to a News & Observer analysis of state records. They’re classified as a type of accidental death known as misadventure.”

And they’re handled almost entirely out of public view.

The N&O examined records of all known misadventures in the state between 1989 and 1993. Those records, along with interviews with key state officials and relatives of 16 victims, showed that:

The Office of the Chief Medical Examiner, which is supposed to investigate all accidental deaths and rule on what caused them, has no obligation to notify anyone about fatal medical errors—or to identify the person responsible. Records often detail the sloppy practice that contributed to a death but rarely name the doctor involved.

“We don’t figure out ‘who done it,’” Chief Medical Examiner John Butts said. “We figure out what done it.”

The state agency responsible for weeding out bad doctors, the N.C. Medical Board, doesn’t track misadventures. The medical board has not asked

the chief medical examiner for records of fatal errors, said Walter M. Roufail, a Winston-Salem physician and president of the medical board.

“Usually, when it is not mandated by law, we don’t go ask for those kinds of things,” Roufail said. “It has never been brought up, to be perfectly frank. I will be happy to raise it in front of the board.”

The board meets in Raleigh on Wednesday.

Hospitals conduct extensive reviews of errors, but doctors and hospitals vary in the amount of information they provide to families about fatal mistakes. No law requires that families be notified of such errors. Hospital review records stay secret.

Fatal errors are supposed to be referred to Butts’ office by the doctor—in fact, by anyone who has knowledge of them—but that doesn’t always happen. The state Vital Records Section, which codes all death certificates, has records of some misadventures that had not been referred to Butts’ office for investigation.

The chief medical examiner’s office identified 59 misadventure cases during the five years from 1989 to1993; Vital Records identified 105. Not counting duplicates, the total misadventures numbered 131.

Some of the difference comes from the way the agencies define misadventure, and some is due to errors or improper reporting. The state doesn’t require the two offices to compare notes.

Fatal errors affect a tiny fraction of the 860,000 people who are treated in the state’s 120-plus hospitals each year.

Autopsy reports show such mistakes sometimes happen when trouble is expected—for instance, during complicated heart surgery. But one woman bled to death after getting her fallopian tubes tied. Another died after a doctor lacerated her uterus during an abortion.

One man died when orange juice was poured down a tube into his lungs instead of his stomach. Others died from anesthesiology errors or hospital drug overdoses. Occasionally, air is inadvertently injected into a patient’s bloodstream. And a frequent type of misadventure involves patients who die from internal bleeding after a doctor pierces an artery—or an organ—during surgery or catheterization.

Kirby Moore’s family found out about the mistake that killed him not from the doctor or from Wesley Long Hospital, but from an autopsy report they requested from the chief medical examiner.

The Moores were shocked when they read the report, Alan Moore said.

“It was completely different than what any of the doctors had told us,” he said.

A misadventure does not always equal malpractice, but it did in this case. The family sued and, after a trial last summer, a jury found the doctor, Robert L. Lawrence, negligent. The jury awarded the Moore family $225,000 plus interest and court costs. Lawrence had no comment.

Alan Moore said he and his family decided to sue partly because they thought court action was the only way to bring details of Kirby Moore’s death to light.

“Under our system, there is really no disciplinary procedure for doctors, and this was the only avenue available to us,” Moore said. “We looked into {hospital} peer review, but that’s a closed process, and the family is never advised as to what steps the hospital takes.

“We looked into filing a complaint with the board, but we found that the number of findings against doctors is so low—clearly that’s not an effective forum for us. So this seemed like the only way to express our outrage at what happened.”

Some families never get that chance.

Although autopsy and investigation reports at the chief medical examiner’s office are open to the public, that office does not notify relatives when it discovers that a medical mistake caused their loved one’s death.

“I don’t want to use the word finking—or tattle-telling, I suppose—but I think it would put us in a delicate political position vis-a-vis the medical community,” Butts said. And some families would be upset if they received an unsolicited autopsy report from his office, he said.

Christine Jones of Rural Hall said the medical examiner’s report was the first information she received identifying the doctor’s error involved in the death of her mother, Tena Joyce, during a pacemaker operation at Forsyth Memorial Hospital in Winston-Salem five years ago.

Jones said she suspected problems when the operation, which she had expected to last 45 minutes, was still under way after two hours. She and her father—Joyce’s husband, Graham—could do nothing but wait.

“The next thing we know the surgeon and the cardiologist and the nurses walked into the room with a tray with little pills and cups of water, and they told us she was gone,” Jones said. “Daddy kept asking what did they mean, and the cardiologist said he didn’t know what happened.”

According to the medical examiner’s report, doctors had lacerated Tena Joyce’s vena cava, one of the large veins that feed blood into the heart. Joyce’s blood poured into her chest cavity, her right lung collapsed and she died, according to the autopsy.

The report established the error as a cause of Joyce’s death. But Jones said the malpractice lawyers she consulted refused to take the case. One told her it would be hard to win because the doctors were well known, and good. Another told her that the doctors would argue that cancer treatment Joyce had received five years earlier had thickened the area around her heart, complicating the pacemaker insertion.

The doctor listed on the autopsy report and Forsyth Hospital staff members declined to comment on the case.

The lack of public review doesn’t mean errors go unscrutinized.

All hospitals have systems to identify shortfalls in care, monitoring or oversight that can lead to fatal errors. For example, they screen doctors and nurses, monitor the number of post-surgical infections and keep track of medication errors.

When fatal errors do occur, most hospitals assign a doctor or group of doctors to review the incident—a process known as peer review. If they find a doctor or nurse has made an error, they can recommend counseling or additional training. In serious cases, the staff nurses are fired and doctors are barred from using the hospital.

Unless a hospital revokes or limits a doctor’s right to practice or pays out a malpractice claim, the case never gets reported to the N.C. Medical Board. Either way, the findings and proceedings of in-house hospital peer reviews are not made public.

The N&O talked with members of 16 families who lost spouses, siblings, parents or children to misadventures. Some said they were told immediately that an error might have occurred; some believed they were misled about the cause of death.

Delford Stickel, a Duke University Medical Center surgeon who leads the hospital’s quality care committee, said doctors sometimes don’t know right away what caused a patient’s death. Sometimes they don’t share information, he said, because they aren’t certain until an autopsy is performed.

“It is not always obvious up front whether it was a mistake or an unfortunate complication that happens in some percentage of cases,” he said.

The threat of a malpractice suit may keep some doctors from sharing all the details of a misadventure with survivors.

Nine-month-old Christopher Summerville was supposed to get 150 cubic centimeters of fluid to treat a virus when he was hospitalized in January 1990. Instead, staff members at Park Ridge Hospital in Hendersonville gave the boy 900 ccs. His parents, Janet and William Summerville, watched in horror as their son began having seizures.

“We took him in relatively healthy, and six hours later he was brain dead,” Janet Summerville said. “He had never been ill before except for a slight ear infection.”

The medical examiner ruled that the baby died from a fluid overload. The Summervilles said the initial information they got from the baby’s doctor failed to explain exactly why their baby died.

But the pediatrician in charge of the baby’s care, James Volk, said he took responsibility for the death and was devastated by it.

“Part of the problem that we have as physicians is that we are at the mercy of our medical malpractice insurers,” he said. “I believe that some of the medical malpractice insurers recommend that physicians not inform patients unless they are specifically asked, ‘Was my injury caused by such and such?’ That is changing, but that was the impression I had when my case came up.”

It didn’t help the defense. The Summervilles won a $1.4 million malpractice award.

c photo; file; 2 photos; file; Caption: Arthur Kirby Moore died in 1991 at Greensboro’s Wesley Long Hospital after a surgeon sutured a piece of tissue over his larynx, suffocating him. Tena Joyce, shown with her husband, Graham, died in 1990 while doctors were trying to implant a pacemaker for her heart. Nine-month-old Christopher Summerville received a fatal overdose of fluid to treat a virus at a Hendersonville hospital in 1990.


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