Father dies after suffering stroke and neglect in the hospital
On February of 2010, my father, at the age of 89, was admitted to a hospital in Washington for an evaluation because he started showing signs of slight confusion. At his admission, he was in a fairly good state of health. He did not have any serious life threatening illness. However, he suddenly died at the hospital on the 5th day of his admission while receiving combinations of anticoagulant medication (Aggrenox, IV Heparin, and Oral Warfarin). He had a sudden brain hemorrhage within 15-20 hours after receiving the increased dosage of 7.5 mg Warfarin and passed away less than 12 hours after the hemorrhagic stroke. Initial dosage of Warfarin was 5 mg.
The summery of his hospital stays were as follows:
Following his admission, the tests showed he had a urinary tract infection. Doctor stated “the infection had caused him the confusion.” They also did a CT scan and an MRI on the brain. It showed a minor blood clot on the left frontal lobe that had occurred six months earlier which was found on the left frontal brain. My father had never learned of the clot since he had no physical or neurological signs and symptoms from that clot incident during the six months period.
Neurologist recommended starting the patient on “Aggrenox.” The neurologist never seemed to care for or follow up on this patient after prescribing Aggrenox, she just let the osteopathic physician to care for the elderly patient’s stroke. Second day of his admission, he was found to be in atrial fibrillation by the osteopathic physician. With the new diagnosis, this osteopathic physician started on the patient right away the anticoagulant treatment of IV Heparin and oral Warfarin. The Federal Agency reviewed the case by its’ own medical doctor and found “the timing of starting Heparin and Walfarin in the setting of acute stroke has been a subject of controversy. The consensus is generally to wait for some time (typically two weeks) after an acute stroke because of the increased risk of bleeding, except in special circumstances. Those special circumstances were not clearly identified in your father’s case. The time at which your father began treatment with Heparin and Warfarin represented a departure from the standard of care, and this has been addressed with the physician.”
My father had confusions at times but did not have any other neurological complications. These three combinations of anticoagulant medication was continued for three days and on the third day, the osteopathic physician increased the dosage of Warfarin to 7.5 mg without consulting a neurologist. The day when the dosage was increased, my father had complained about dizziness and continuous indigestion all day long. Within 14-20 hours after receiving the increased dosage, he suffered a sudden hemorrhagic stroke and passed away very soon on the same day. Coagulation lab test showed very high P.T.19.6(reference Range 12.0-15.0) few hours prior his brain hemorrhagic stroke however, this was ignored by nurse and the physician.
From the bottom of our hearts, we knew he did not die from natural causes or coincidentally, from the sudden bleeding that occurred that time. It happened when he was an inpatient for several days under improper care of the osteopathic physician who had no knowledge of the crucial waiting period, and the negligent neurologist, negligent nurses. He was receiving anticoagulant medication continuously at the wrong time. We took him to the hospital to prevent this type of unfortunate and unexpected death. However, ultimately, his life was ended abruptly by a disqualified osteopathic physician, and the neurologist’s malpractice and nurse’s negligence as well as the hospital’s negligence. The nurse and her charge nurse checked my father 11 hours prior his passing and noticed serious neurological status changes. She wrote on her Acute Care Record: “patient self-moaning; left arm, left leg not moving; his grips-unequal (R greater than L); left side facial droop”. Also wrote “patient awake, groaning in bed, pt. not answering questions at this time, pt. holding tele-monitor in right hand, not letting go, pt. not following commands at this time not squeezing hand equally. Will continue to monitor.” These descriptions of symptoms which even non-professionals are able to identify that the patient is suffering from a sudden stroke, was neglected by the registered nurse and her charge nurse for more than 1 hour and 15 minutes until my family came to see my father who showed signs of significant stroke. We can assume he was holding tele-monitor with his right hand in an attempt to get help, he grabbed anything he could reach with his right hand.(since left side of his body was already paralyzed).
The nurse later claimed to the Washington State Department of Health investigator that the patient did not seem to speak English, and therefore did not respond to her comment, so she decided to keep monitoring, which makes absolutely no sense to us. My father was well able to speak English conversationally. If she truly believed that he was unable to respond due to language barrier, then why did she not immediately call for an interpreter given the urgent situation? Does law not require that the hospital provide an interpreter? (State investigator failed to question the nurse about her failure calling the interpreter). My father could not respond to anyone at that time, not because he did not know how to speak English, but because he was already suffering from the serious stroke due to the bleeding in the brain.
The Federal agencies’ investigation had newly found the nurse actually paged the physician(D.O.) when she first noticed my father’s stroke at 7:00am but the physician never showed up however she and her charge nurse never again attempted to call any physician who can help this seriously suffering stroke patient for more than 1 hour 15 minutes until the family came to visit the patient and noticed his condition(his left side facial drooped, paralyzed, unable to speak) and requested immediately to notify the physician.
My father’s sudden bleeding in the new area of right front of brain occurred around 15-20 hours after receiving increased dosage of 7.5mg Warfarin. The timing of starting anticoagulant medication on this patient was proven to be at the wrong time and had caused the deadly bleeding in the brain. We also believe he was overdosed which ultimately caused his sudden, unexpected death. The osteopathic physician and neurologist’s decision of anticoagulant treatment on an 89 year old patient should be sought after sufficient consideration of the dangerous side effects of brain hemorrhage especially on elderly patients. The hospital should not have been allowed this unqualified physician (who had no knowledge of crucial waiting period) to care for any stroke patent. These nurses’ obvious neglection on serious stroke suffering patients is outrageous.
The hospital also failed to provide immediate and essential care to the sudden stroke suffering patient for a very long time which he desperately needed and deserved as inpatient. The osteopathic physician finally arrived after 45 minutes from the family’s request (2 hours from first notification of stroke), and ordered a CT scan of my father, but the CT was done more than 2 hours later from his order. Why did the hospital staffs and the physician left a paralyzed, urgent patient wait for so long? Any logical person would know how to prioritize the urgent patient. His patient rights and the standard care were seriously violated.
For the last 2 and a half years since my father’s passing, I have been putting all of my efforts hoping to find the truth through the Washington State Department of Health investigation. However, the Hospital, Medical, and Nursing Commissions repeatedly ignored the facts in the case and closed the case with no cause for actions after 8-10 months long investigation. They did not seem to perform the thorough investigation as they claim to do so. It is already tragic to lose my father unexpectedly; however, every agency in the State Department of Health, in the name of protecting patient’s right and better care, added insult to injury to the family already suffering the great loss of loved one. It is an abuse of their power and the system, which is not right and seriously needs to improve.
We decided to file complaints to federal agencies out of frustration and great disappointment of the State Department of Health. The federal agencies all concluded after their own investigation that many of our allegations were substantiated. I filed complaints to the Secretary of WA state Department of Health in regards to its failed investigation but I haven’t received a response yet.
We have deep concerns related to the quality and necessity of medical care that my father received during his less than 5 days of hospital stay. We believe he was neglected by the hospital, physicians, and nursing staff due to his age. This is obviously an elderly abuse. We believe he was not the only patient who received improper care and wrongfully lost lives. We believe similar incidents have been going on for a long time in this hospital to many unknown patients, however unnoticed, overlooked, and ignored.
Our family hopes that my father’s tragic story can help and inform other family preventing to go through what we are going through.
By Kimberly Yang