Fatal Medical Misadventures
From the News & Observer Story Archive
July 16 1995
Fatal Medical ‘Misadventures’ Kept Under Wraps
Page A1, Sunday
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By TINKER READY and PAT STITH
STAFF WRITERS
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 upfront 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.
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