CORONERS & CORRUPTION

It may come as a surprise to you, but accidental deaths occur in American hospitals at an alarming rate. At the end of 1999, the highly respected (“IOM”), a division of the National Academy of Sciences, issued a report in which it estimated that there are 98,000 accidental deaths in American hospitals each year, equating to about 15% of the hospital population. That means that there may be about 15,000 accidental deaths per year in hospitals in America.

Ninety-Eight Thousand accidental deaths is more than twice as many as the number of people killed by cars. It’s as if 400 Boeing jets- each with about 250 passengers went down every year. Imagine the fervor over that.

One of the reasons that the accidental death rate is so high and why there is no public outcry is Hospitals, doctors, and nurses keep a lid on it. If word got out, that would be “bad for business.” Secrecy and “double-record keeping” are encouraged by state laws that, in almost all states, forbid disclosure of any of the information gathered in a process known as “peer review.” This takes place in a hospital after a patient death or injury that has been caused by a mistake. Doctors, nurses and hospital administrators look at what happened and try to prevent it from occurring again, but because the process is secret, there is no independent, public review of the accident’s causes or of the medical establishment’s remedy.

While state and federal laws require that a patient’s true course and treatment be recorded in the patient’s medical records, when a mistake results in death or injury, the patients’ medical records are routinely rewritten, or information about what happened is omitted from the patient’s record, or both.

The result is “double record keeping.” There are the peer review records, which accurately reflect what occurred; and there are the patient’s records, which are usually falsified.

The report, To Err Is Human, describes a “culture of secrecy” which envelops these tragic mistakes. Because of this secrecy, the Institute could only estimate the number of accidental deaths in hospitals. Neither the Institute nor anyone, else knows the true number of accidental deaths which occur in hospitals in the United States. County Coroners and County Medical Examiners play a role in keeping accidental deaths in hospitals secret. Coroners are charged by law to investigate accidental or suspicious deaths on behalf of the public. Public knowledge of why someone has died is extremely important in a democratic society. If a person can die from undisclosed causes, individual liberty is at risk. A hallmark of totalitarian societies is the fact that a person may lose his life without public knowledge of the true circumstances of death.

With regard to accidental deaths which occur in hospitals, however, Coroners are first and foremost politicians. They are elected office holders, and no politician ever fattened his campaign coffers or won votes by wrangling with hospitals and doctors. Hospitals are generally loved by the community, and they are also large employers. Physicians comprise one of the most powerful interest groups in our society. A Coroner who attempts to expose an accidental death that a hospital wants to conceal will not win any friends.

Further, Coroners usually do not have any kind of medical degree. They are not “forensic pathologists.” Forensic pathology is the study of human tissues and fluids to determine the cause of death. Because Coroners are not professional forensic pathologists, they are unlikely to have the same degree of professional interest in the science of forensic pathology as physicians who have trained for several years in that science. A Coroner may lack the wherewithal to determine whether the forensic pathology being performed by the Coroner’s Department agents on behalf of the public is adequate. While citizens can be certain that their County Coroner wants to assist law enforcement in apprehending and convicting criminals, they can be just as certain that their County Coroner will be very reluctant and very unlikely to apply the same diligence in trying to discover that a patient died from a mistake in a hospital. Here are some examples of what I am talking about.

MIGUEL KOVAL - 51 YEARS OLD

DIED AFTER ELECTIVE WRIST SURGERY

In 1993, Miguel Koval went to Kaiser Redwood City for elective wrist surgery. He suffered respiratory failure after the surgery because of an accidental overdose of morphine. The lack of oxygen to his brain caused him to suffer severe brain injury. He was found unconscious at about 2:30 a.m., following the overdose, which happened at about 1:20 a.m. Right away, he was given a morphine antidote, and for about 40 minutes he was alert. During that time clinical examination revealed that the oxygen deprivation had caused severe damage to his motor cortex. He could barely move his limbs, and he had lost control of his tongue. He then lapsed into a coma and needed to be placed on a ventilator.

When the analgesic effect of morphine was reversed by the antidote at about 2:30 a.m., he screamed out in pain. His brain was not so damaged that he couldn’t still feel his surgical pain. His screaming woke up a nearby patient, who herself was a nurse. She came forward during the trial and testified convincingly about what she had seen and heard.

Miguel’s medical record falsely reported that he had experienced an uneventful night that he had been seen in normal condition at about 6:00 a.m., and that at about 6:30 a.m. his nurse found him unconscious in bed.

At about 9:30 a.m. the family was notified that Miguel had a “problem.” When they went to the hospital, they were told the false version of what had happened. By then Miguel was in a coma from which he could only be roused when his physician shook him and shouted at him. Then, he would barely open his eyes and he would attempt to follow commands like “wiggle your big toe.”

Although Miguel was in a coma that was ultimately caused by the hospital’s deadly overdose of morphine, the family was told that Kaiser doctors did not know what was wrong and that they were doing tests to find out. The family was led to believe that Miguel would probably pull out of the coma after he received a drug to reverse the effects of morphine.

Of course, Kaiser doctors knew that Miguel had suffered a brain injury, but they did not want to tell the family the truth. If they had told the family the truth, his doctors would have been required to discuss life-saving treatments with the family. By not telling the family about his injury, they would not have to consider giving him treatment to prevent brain swelling. Brain swelling results when brain tissue is injured, either from trauma or lack of oxygen. Brain swelling is fatal unless it is treated, because as the brain tissue swells, it squeezes the blood vessels in the tissues shut and cuts off blood flow, which leads to further injury and swelling. Eventually this process causes the brain to die, and thus spares Kaiser the expense of caring for a brain damaged patient.

At about 8 p.m., some 18 hours after his brain injury, Miguel suffered brain death (His swollen cerebellum crushed his brain stem.). Treatment with steroids and removal of the back of his skull would have most probably avoided this result but Kaiser doctors, without discussing this decision with Miguel’s family, decided that Miguel would be better off dead than alive.

Kaiser doctors told the family that they did not know why Miguel had died. His body was taken to the County morgue for examination by a forensic pathologist working under contract for the San Mateo County Coroner, Bud Moorman. Dr. Peter Benson was the pathologist who performed autopsies for Moorman on people who had died for unknown reasons.

I spoke with Dr. Benson before Miguel was autopsied. I wanted to know if the family should retain a private forensic pathologist. He assured me that it was unnecessary because he would determine how Miguel died.

Luckily, Dr. Benson retained Dr. Richard Davis to examine Miguel’s brain. Dr. Davis is a world-renowned neuropathologist, who was then a professor of neuropathology at UCSF. Neuropathologists specialize in the study of brains after a person has died from an illness of the brain. Dr. Davis autopsied Miguel’s brain. He concluded that Miguel died from a brain injury caused by respiratory failure that was caused by morphine.

After a final death certificate had been issued by Bud Moorman, which stated that Miguel had died from a brain injury caused by respiratory depression secondary to morphine, the physician director of the Medical-Legal Department at Kaiser Redwood City contacted the Deputy Coroner and requested a further “review.”

tDeputy Coroner and requested a further “review.”

Dr. Benson was only too happy to oblige, and, with Dr. Davis no longer involved, he issued a new report that said that Mr. Koval had died from a stroke. Mr. Moorman, with Dr. Benson’s report in hand, then issued a new certificate of death which stated that Miguel died of a stroke.

Armed with this new death certificate, Kaiser could claim in court and assert to independent reviewing agencies that Mr. Koval had died of a stroke, a medical illness, and that he had not died because of malpractice.

This change in the cause of Miguel’s death was not based on science. It should have been clear to Moorman that Kaiser was engaged in falsifying what happened to Miguel. One striking anomaly was that a hospital urinalysis of Miguel’s urine was negative for opiates. That result was impossible given that the hospital reported that Miguel had been given morphine post-operatively to control surgical pain. His urine had to contain opiates if he had been given opiates. Mr. Moorman never investigated this anomaly.

When I finally examined Dr. Benson under oath about why he reached a different conclusion from Dr. Davis about the cause of Miguel’s death, it took about six hours of questioning before he admitted that the change was not based on science. He finally admitted that for all he knew “someone at the hospital could have put a plastic bag over his head and suffocated him.”

I made a promise to myself then, that if I ever had this problem again with a falsified cause of death to “help out” a local hospital, I would sue that Coroner.

MARK MILLER - 41 YEARS OLD

DIED AFTER RECEIVING MORPHINE

FOR ACHILLES TENDON RUPTURE

In 2001, I filed a lawsuit against the Contra Costa County Coroner, Sheriff Warren Rupf. In that lawsuit, which is on file with the Superior Court, I have alleged that he assisted Kaiser Permanente in covering up the accidental death of Mark A. Miller, a 41-year old man with two teenage children whom he had raised himself as a single father after he and their mother divorced.

The complaint alleges that Mr. Miller went to the hospital with a ruptured Achilles tendon. It alleges that he was admitted for an overnight stay in the hospital prior to the surgery which was planned for the next morning, but during the night while in his hospital room he died.

In the complaint it is alleged that Mr. Miller died from morphine overdose and that his morphine overdose was caused by a “Patient Controlled Analgesic Pump (“PCA”). The PCA pump, to which he was attached, is a device which permitted Mr. Miller to self-inject morphine during the night. The complaint maintains that something went wrong with the pump during the night which caused him to receive doses of morphine considerably larger then he was supposed to receive.

The complaint alleges that in the morning, a Kaiser physician phoned the Coroner’s office to report Mr. Miller’s death. It further states that during the conversation between the Kaiser physician and a Deputy Sheriff working in the Coroner’s office, the two of them came up with a “story” which “concluded” that Mr.Miller had died from cerebrovascular disease, i.e., from natural causes.

This “diagnosis” was allegedly made by the Deputy, who had no medical training. The Deputy claimed that he was not told that Mr. Miller had been receiving morphine and conveniently the Deputy “forgot to ask.” State law mandates that the circumstances surrounding a death may not be altered if the Coroner assumes jurisdiction. Because the Deputy declined jurisdiction, Kaiser was free to remove the equipment that had been used to treat Mr. Miller and which had caused his death.

When the Deputy refused to assume jurisdiction over Mr. Miller’s death, the complaint alleges that Kaiser employees then removed the PCA pump, and a cardiac monitor, a cardiac monitor strip, syringes, tubing, etc. from Mr. Miller’s room.

The complaint further alleges that about an hour after the Deputy Sheriff declined to take jurisdiction, another Kaiser doctor called the same Deputy Sheriff and allegedly said to the Deputy, “Did you know that Mr. Miller was on a morphine pump?” Upon hearing this “news,” the Deputy said, “Oh! The other doctor forgot to tell me that Mr. Miller was on a morphine pump, and I “forgot” to ask. So don’t touch a thing till I get there.” Of course, by then, everything that Kaiser did not want the Deputy to see had been removed.

After Mr. Miller’s body was brought to the County morgue, an autopsy was performed by Dr. Brian Peterson, who is a partner is a group called Forensic Medical Services, Inc. Dr. Peterson issued a report that Mr. Miller died from “cardiovascular disease.” That was the same “diagnosis” of the cause of death that the Deputy Sheriff made.

The first problem is that “cardiovascular disease” is not a statement of a cause of death. It is only a statement of a medical condition. Therefore, the death certificate based on Dr. Peterson’s report does not comply with state law because it does not explain how “cardiovascular disease” caused Mr. Miller's death.

The second problem with Dr. Peterson’s work was that he did not review Mr. Millers’s medical records. When I was taking Dr. Peterson’s deposition, I asked him if he had reviewed the medical records of Mr. Miller. He testified under oath that he had not. I then asked him how he learned about Mr. Miller’s hospital course and he answered that the Deputy Sheriff had told him about it. I admit that when he said this I was flabbergasted. The Deputy has no medical training whatsoever, yet apparently he was allowed to become the principal medical authority in this matter, notwithstanding the availability of numerous licensed physicians and nurses who were involved in Mr. Miller’s care and the circumstances of his death. I thought that Dr. Peterson would have reviewed Mr. Miller’s medical records and spoken with his attending nurses and doctors if he were going to conduct an honest investigation into why Mr. Miller died.

That Dr. Peterson would attempt to state a cause of death without examining the medical records is patently absurd. It is simply not possible to believe that Dr. Peterson would have relied on the report of a hearsay witness who has no medical training when Mr. Miller’s doctors could have been interviewed and his medical records examined.

Thirdly, Dr. Peterson performed an autopsy on Mr. Miller after his heart had already been removed for use by another patient who needed it.

Fourth, Mr. Miller did not have cardiovascular disease.

Fifth, when I deposed Dr. Peterson, I asked him to tell me why Mr. Miller died. He testified that he died from “cardiac arrhythmia,” which means left ventricular fibrillation. This conclusion was not stated in the autopsy report, and it is a complete fabrication. The nurse who found Mr. Miller unconscious reported that Mr. Miller’s heart was beating with a normal rhythm. Cardiac “arrhythmia” means precisely the opposite of a normal rhythm.

Plaintiffs hired a UCLA cardiologist (emeritus), who had been on the faculty there for over 30 years. He is a highly respected cardiologist. He filed a declaration in Court in which he stated that he was 99% certain that Mr. Miller did not die from a primary heart attack of some kind, i.e., Mr. Miller’s death was not precipitated by his heart. Rather, he stated, under oath, that the most likely cause of Mr. Miller’s death was due to morphine, and probably morphine overdose.

Why would Dr. Peterson prepare a fraudulent autopsy report?

Money is one reason. The Forensic Medical Group has a significant, economic relationship with Kaiser - Permanente. Forensic has two contracts with Kaiser to perform autopsies on the bodies of deceased Kaiser patients to assist Kaiser physicians in learning about how medical care failed or succeeded in these patients. Thus, Forensic has an economic incentive to protect its business relationship with Kaiser by providing reports about deaths in their hospitals on behalf of the Coroner which protects Kaiser from lawsuits for accidental deaths.

Thus, even if Dr. Peterson were an honest broker working on behalf of the public, and even if the circumstances which surrounded Mr. Miller’s autopsy did not raise the stink of actual fraud, Dr. Peterson should not be performing autopsies on behalf of the County of Contra Costa which involve persons who may have died accidentally at the hands of Dr. Peterson’s other employers.

I have brought this conflict of interest and this fraud to the attention of the Coroner, of the Board of Supervisors and of the Courts. Not one of these governmental agencies has shown much concern about this problem Judge David Flinn threw my lawsuit against the Coroner out of court. It is now on appeal. Meanwhile, Judge Flinn was unable to throw out of Court, entirely, the lawsuit against Forensic. Plaintiffs have been permitted to proceed with their claim against Forensic for deceptive business practices.

MIDDLE-AGED MAN

DIED AFTER RECEIVING OPIATES

FOR PAIN

Because of the sensitive nature of this death at the present time, I have changed the circumstances of this death to conceal the hospital (not a Kaiser hospital) which is involved in this matter, but the general facts are true.

A man in his 40's was admitted to a hospital in for pain in an area of his back. The reason for the admission was the possibility that the man had meningitis (which, as it turned out, he did not have). This man had no significant medical problems or history of illness, e.g., no heart problems. He received opiates to relieve his pain and was found dead in his bed sometime during the night.

When Forensic Medical Group did the autopsy on this man it had his blood tested for opiates. The test showed no opiates in the decedent’s blood. Forensic then concluded that this gentleman, like Mr. Miller, had died from a sudden heart attack.

The man’s family had a private autopsy performed. The pathologist who performed the private autopsy took blood right from the man’s gut. When tested by an independent laboratory, this blood contained a lethal level of opiates.

The surmise is that Forensic tested blood that had been taken from the decedent when he first came into the hospital, which did not, of course, contain opiates because the decedent had not received the opiates yet.

As in the Koval matter, the Coroner and Forensic should have been alerted that analysis of the decedent’s blood was suspicious. The decedent was reported by hospital employees to have been given opiates. Opiates are highly controlled drugs. The disposition of all quantities of opiate medicines must be recorded in writing and reported to the Federal government. It is a criminal offense for a nurse to record that she gave a patient an opiate when she has not. A test result which showed that this man had no opiates in his blood was an inaccurate result if the decedent had received opiates within 36 hours before his death.

When this man’s blood test showed no opiates in his blood, Forensic and the Coroner were obliged to determine why. The only possibilities were (1) the decedent had not received opiates; (2) the wrong blood had been tested; or (3) the test was, in some manner faulty.

Instead, Forensic, acting on behalf of the Coroner and the public, simply ignored the anomalous result, and concluded that the decedent had died from a heart attack, just as it had concluded that Mr. Miller had died of a heart attack.

The failure to investigate and explain this anomaly was in the interest of the hospital. It permitted Forensic to issue an autopsy report which exonerated the hospital from being at fault in causing this man’s death. However, the failure to investigate this anomalous test result was a breach of the Coroner’s duty to determine how this man died. It is not acceptable behavior by a public official and it must be stopped.

JOEY DEIL - 20 YEARS OLD

MALNUTRITION AND DEHYDRATION

Joey Deil was a 20-year old severely retarded young man who was being cared for in a group home in Contra Costa. He could not communicate with language. He was reportedly found dead, in his bed, by a group home employee where Joey lived. Dr. Peterson of Forensic weighed Joey Deil after his death at 95 pounds. Joey was about 5' 6" tall. His normal weight was over 120 pounds. Dr. Peterson refused to perform an autopsy, and said that Joey had died from a seizure.

The family had a private autopsy done, which revealed that Joey had no body fat internally. Moreover, his internal tissues were unusually dry. There was no fecal matter in his intestines and no food in his stomach. The private pathologist concluded that Joey died from malnutrition and dehydration based on these autopsy findings.

The failure of Forensic to do an autopsy resulted in a failure to discover the true cause of Joey’s death. Without the information provided by the private autopsy, the lawsuit which the family has brought against the care facility could not have gone forward. Equally important is that by failing to do an autopsy, the failed in his public duties - to warn authorities that this particular care facility was not providing proper care for adults who are unable to care for themselves. The information that may be learned from an autopsy can be very important for the safety of other members of the public.

The probable reason that Dr. Peterson refused to perform an autopsy on Joey Deil has to do with money. Forensic’s contract with the County limits the amount of money that Forensic can earn. If it performs more autopsies then its contract with the County provides for, it risks doing more work then the County is obligated to pay for.

LARRY LINCHNER - 53 YEARS OLD

DIED BEING TREATED FOR A BROKEN ARM

In Solano County, Larry Linchner, 53-years old, fell into hole while on a fishing trip and broke his right arm. He was taken by ambulance to a Kaiser Hospital in Vallejo. By the next morning he was dead.

When the family asked that an autopsy be done, a pathologist working for Forensic told the decedent’s brother-in-law that no autopsy would be done because Mr. Linchner died of a “heart attack.” When Mr. Linchner’s brother-in-law insisted by asking, “Can you see through skin?,” the pathologist retorted, “If you want an autopsy, do it yourself.”

No private autopsy was performed because Mr. Lincher’s family did not know how to go about getting one done, nor could they afford the $3000 to $4000 that a private autopsy costs.

Mr. Linchner did not die from a heart attack. I have not yet really dug into this case yet, but from what I was told about the condition of his body, he probably died from anaphylactic shock, i.e., an allergic reaction to medicines. Mr. Linchner received medical care, when he needed it, from the Veteran’s Administration. Instead of taking him to the Veteran’s Hospital in San Francisco, Kaiser Vallejo admitted him. His family asked that he be taken to Veteran’s Hospital but for reasons that are not clear he was kept at Kaiser and treated there. Kaiser, of course, had none of his medical records. The family states that they told Kaiser personnel that Larry had some medications that he was allergic to. But apparently, Kaiser care givers did not pay enough attention.

COUNTY GOVERNMENTS AND THE

COURTS REMAIN INDIFFERENT

TO THIS ABUSE

As I have done in Contra Costa County, I am just about ready to file a law suit the Solano County Sheriff/Coroner. As I did in Contra Costa County, I contacted the local newspapers. It seems like there is just as much indifference in Solano County to this problem as there is in Contra Costa County. I’ll see what happens. I suppose everyone is afraid of tangling with the County Sheriff.

It is my view that both these Sheriffs are passive actors in what amounts to government corruption. The office of the Coroner is being corrupted by the physicians who own and operate Forensic. Neither Sheriff Rupf, Contra Costa County, nor Sheriff Stanton, Solano County, should permit a private contractor with an evident, overt conflict of interest to investigate, on behalf of the public, suspicious deaths.

The failure of these Sheriffs to properly conduct themselves as County Coroners is a serious problem. There are no independent witnesses to most accidental deaths in hospitals. Nurses and doctors who are involved in these terrible accidents band together and lie together about them. I have seen this over and over. The only public official who could conduct a pertinent, timely investigation into accidental deaths in hospitals is the Coroner. Coroners are mandated by state law to investigate the circumstances surrounding accidental or unusual deaths. Middle-aged adults undergoing treatment for a wrist problem, a ruptured Achilles tendon, a broken arm and back pain should not ordinarily die in a hospital. All of these deaths should have been competently investigated by the Coroner in each of those counties.

The failure of coroners to conduct competent investigations into accidental hospital deaths promotes carelessness in hospitals. As it stands now there is almost no check on a hospital’s ability to falsify the circumstances in which accidental deaths occur. The families of decedents and their attorneys are virtually powerless to find out what actually happened within a hospital that caused a family’s loved one to die unexpectedly.

Further, families in California lack any effective means to correct or punish a medical care giver for a mistake. Because of MICRA, the 1975 law limiting damages, hospitals usually pay very little for their mistakes which kill patients. Without any effective means to make hospitals pay for their mistakes, hospitals will never spend the money and exercise the diligence needed to reduce accidental deaths to “zero.” That is why 15,000 or so patients die accidentally each year in California hospitals.

Coroners should be acting in defense of the public by recognizing that competent and honest investigation of accidental deaths in hospitals should be an important part of their mission. They, no doubt, understand that they should provide assistance to District Attorneys in prosecuting criminals who murder or injure victims. But the Coroner’s legal mandate is far greater than that. State law imposes Coroners the duty to investigate accidental and suspicious deaths, which should include accidental deaths in hospitals. Citizens deserve far better than what they are getting from their Coroners and their elected officials and Judges in this regard.