University of Michigan Hospital officials didn't forward report on 'suspicious death' to police 4 years ago
University of Michigan Hospital officials didn't forward a report on a "suspicious death" of a patient to university police in 2008, prompting police to investigate a hospital security captain for obstruction of justice.
No charges were filed against the captain or anyone else, the Washtenaw County Prosecutor's Office said in response to a Freedom of Information Act request filed by AnnArbor.com.
University of Michigan Hospital
AnnArbor.com reported in January that university officials waited 6 months to report it to police after child porn was found last May on a thumb drive left in the Pediatric Emergency Department at U-M Hospital. The Board of Regents on Thursday ordered an external review of that case, less than a week after the university released an internal review, saying an outside expert would be brought in to help make changes.
U-M regents also expressed concern about the blurred lines between hospital security and university police.
Search warrant affidavits in the 2008 case show that the child porn incident wasn't the first time hospital officials - including security - failed to contact police after a crime was alleged. The case centers around the Dec. 11, 2007 death of 79-year-old Dorothy Porterfield, who was being treated at the hospital for an aggressive form of lung cancer.
When she was found dead at 3:27 a.m. on the general care floor of the hospital, an affidavit says, her tracheostomy tube "had been removed and was on the floor." One of her daughters was in the room, sleeping. Officials at the Washtenaw County Medical Examiner's Office told AnnArbor.com that they weren't contacted when Porterfield died. Her death certificate listed the cause of death as cancer.
The family paid for an independent autopsy that found the cause of death was asphyxiation "due to the dislodgement of the tracheostomy tube." Cancer was listed as a contributing factor and there were no physical injuries. However, without a police investigation, the doctor who conducted the autopsy couldn't determine the manner of death because it was "unclear how the tracheostomy tube was dislodged."
Suspecting foul play possibly by a hospital employee, a family member "requested to file a police report" and filed a report with hospital security on Feb. 24, 2008. "The report was not forwarded to the U-M police," an affidavit says.
University of Michigan spokesman Rick Fitzgerald said Friday there was no indication of foul play in the death.
"Loss of trach tubes is not unusual and this patient had been documented as pulling at her tube earlier in her care," he said. Fitzgerald said he didn't know how the trach tube ended up on the floor, but the hospital reviewed the incident and found that the patient likely pulled out the tube. An affidavit says it was found across the room.
"We don't know how it was removed because it happened apparently in the middle of the night between visits by the nursing staff," Fitzgerald said.
On April 11, 2008, about a month-and-a-half after filing a report with security, family members met with university police to report that they believed Porterfield died under suspicious circumstances.
Police interviewed a coordinator of autopsy and forensic services at the hospital, who wasn't aware of the case. After reviewing patient notes on the case, she "expressed surprise" to police that the notes showed that "the tracheostomy tube was found not by the patient's bed but across the room," an affidavit says.
Police also interviewed a U-M Hospital Risk Management employee who was investigating, but hadn't completed a report. She told police she "thought the death was suspicious," noting that the only person in the room at the time was a family member. She told police that after she consulted with the security captain, she decided that it wasn't necessary to report it to police, an affidavit says.
Police also spoke to a security sergeant in charge of supervising the security report that was filed and asked why he didn't have an officer write a police report. He told police that he spoke with the security captain, expressing his concerns and the concerns of the Risk Management employee about not filing a police report.
The security captain "told him it was not necessary to write a police report; it was being handled," an affidavit says.
Investigators asked the security captain why he hadn't "directed Hospital Risk Management to report a suspicious death to the police." He told police that Risk Management "did not call him right away," an affidavit says, and "he understood that the patient had pulled out her own trach tube."
Police asked why he didn't make sure police were contacted after the family requested that a police report be filed, but he said he wasn't aware of that request.
Investigators executed search warrants on the security captain's computer and email account, seizing some documents and other items. AnnArbor.com has filed a Freedom of Information Act request with the university, seeking a copy of the police report. Prosecutors said they no longer have a file on the case because the records were purged.
Fitzgerald said Washtenaw County Medical Examiner Bader Cassin was consulted by police in June of 2008, roughly seven months after the death occurred. Cassin reviewed the independent autopsy and some of Porterfield's medical records and didn't support the view that asphyxiation as a result of removal of the trach was the cause of death, Fitzgerald said.
While prosecutors declined to charge the security captain with obstruction of justice, they criticized hospital security, Fitzgerald said. The family's attorney made a claim of medical malpractice, the hospital offered compensation and the family accepted it, Fitzgerald said. The hospital's review found that the patient was probably moved out of intensive care prematurely, he said. Fitzgerald said he didn't know whether changes were made at the hospital after the incident.
"This case, and all the types of clinical situations that hospital security is often called to assist with, will be shared with outside experts we will be engaging to review the protocols and reporting procedures between hospital security and DPS," he said.
Lee Higgins covers crime and courts for AnnArbor.com. He can be reached by phone at (734) 623-2527 and email at leehiggins@annarbor.com.
Comments
M.Erchul
Fri, Feb 24, 2012 : 1:55 p.m.
In response to people making comments about medical issues, they obviously do not know what is done today. Most patients with a trach have a soft neck holder with velcro to hold the trach in. A patient could easily pull it apart. Yes, a trach may have a balloon but many patients do not have that inflated. It is called with the cuff down. So sometimes patients do pull out their trachs. The patient could have easily pulled it out and thrown it across the room. The daughter was sleeping so there were no witnesses. It sounds like the family was looking for something to sue the hospital and someone to blame.
julieswhimsies
Mon, Feb 20, 2012 : 12:18 a.m.
I have run out of words. My husband have always referred to U of M Hospital as "Big Al's Emporium". (A personal joke.) I ride horses every day, and falls are inevitable. I take every precaution....helmet, steel-toed boots, cell-phone on my person at all times. I take my safety very seriously. I am going to ask the owners, if one of them will escort me to the hospital, if EMS insists on transporting me to the U of M Emergency Room. If no one is around , and I am transported to the U against my will, I will simply walk out, and call a friend to drive me elsewhere. These cover-ups are scary, and MUST stop. The hours and hours one must wait to be seen at any time MUST stop. The medical errors MUST stop. The arrogant demeanor of the residents and attendings MUST stop! First Do No Harm! Once I was in the ER for 27 hours, not allowed water or food, and had to make a goddawful scene. By the time they got to me and tried to insert an IV, I was so dehydrated, they poked me over and OVER trying to find a vein. The regular hospital was no better. After hand surgery, I was hooked up to a morphine machine, which broke during the night and flooded me with morphine. A young nursing student "happened" to walk by and noticed my breathing was very shallow. The only memory I have of that night was vaguely hearing people shouting at me. This incident was never mentioned anywhere in my medical records. U of M HEAL THYSELF!
anotheruofm
Sun, Feb 19, 2012 : 4:51 p.m.
NOT ANOTHERUofM COVERUP!!!! "The patient had been documented as pulling at her tube earlier in her care," Fitzgerald says. But what he forgot to add is that the trach tube has an inflatable "bulb" at the inserted end so after the tube is inserted, the doctor "inflates" this "bulb" so the tube cannot be pulled out. You HAVE to deflate the bulb or there would be obvious signs of trauma to the tracheotomy. Even Risk Management thought that this was suspicious yet no one called the police. Sounds like another great criminal investigation done by hospital security. Glad that the police were notified a month and a half after all the evidence was thrown away. Can't wait to hear about the next COVER UP uncovered by Lee.
kjn2012
Sun, Feb 19, 2012 : 11:45 p.m.
Trachs can be pulled out even when the bulb is inflated due to; Trach ties can become loose over time that is why nurses check this and the bulb is not inflated to totally occlude an airway on a trach unless someone is on a ventilator, so you can have a trach pulled out. You can have a trach occlude by an individuals own mucous and therefore, a confused patient may pull the trach out. Or it may not be comfortable for the individual. Many things need to be assessed with trachs especially after they are newly placed. Placing restraints on a patient is not always an answer and placing leather restraints on a already confused patient can aggitate them even worse and making taking care of that individual even more difficult. It sounds like this person was compromised as it was. All I am saying that this is one word we are hearing and there is more to the story. Until all of the evidence is given, it is hard to make assumptions.
joe.blow
Sun, Feb 19, 2012 : 12:59 p.m.
This is getting stupid. AA.com seems to trying to attack UofM for God knows what reason. They're trying to build a case for a coverup, yet every instance they mention the police were involved. AA.com just lacks ethics.
Kai Petainen
Sun, Feb 19, 2012 : 1:53 a.m.
just an observation to those who want to get Prescovitz out of there.... ... this incident happened before she got there.
trespass
Sun, Feb 19, 2012 : 11:35 a.m.
I have not seen a comment on this story that calls for Pesocvitz resignation. There have been some on the child porn stories because the security department and lawyers work fo her.
MARK
Sun, Feb 19, 2012 : 1:47 a.m.
No one get off this earth alive we all die. What ever else you feel about this case we need a dialog about end of life care. Just because you can intervene does not that it is in the patients best interest. You often prolong their death not their life
Matt Cooper
Mon, Feb 20, 2012 : 5:04 p.m.
And you know this...how? It says nothing in the article about her getting close to leaving the hospital, nothing about her recovering, and noting about her care plans. Or do you just presume to know a lot?
trespass
Sun, Feb 19, 2012 : 11:33 a.m.
She was not a hospice patient. She was recovering and getting close to leaving the hospital so end of life care was not applicable in this case.
Mrs. S
Sun, Feb 19, 2012 : 1:16 a.m.
@Sesame45, From the looks at most of your posts, you are most likely a security guard for the hospital. Thats all well and good but your comment about the trach tube being "pulled out" by the patient seem false and misleading. The spoke person for UM said that the patient "has a history of pulling AT" not pulling OUT their trach tube, earlier in their care. And furthermore we don't even know the patients state of consciousness or ability for that matter to pull at or out a trach tube at this later stage in their care. I think the root cause of problems for the UM Hospital have involved misleading statements and obvious deception. Fitzgerald is doing his job by making these new allegations of failing to report a possible crime look as if the UM Hospital routinely deals with these same issues on a regular basis and that it is business as usual. He is not doing a very good job and frankly I am tired of the UM Hospital's business as usual attitude! This must change! I wonder how another hospital would have handled this same situation. One may never know. But one thing that is clear to me is that if there is a sliver of foul-play in a death, no matter how small, is SHOULD and MUST be reported to the POLICE. What if it were your mother or father that suspiciously died? Would you just call security?
Ralph
Sun, Feb 19, 2012 : 12:10 a.m.
Crime at the U of M! What't the difference between these crimes, committed by white collar professionals and the prostitutes on E. Michigan Avenue.? Answer: Nothing! All the king's horses and all the king's men couldn't put Humpty Dumpty back together again.
Kai Petainen
Sat, Feb 18, 2012 : 11:31 p.m.
i hope they can figure this stuff out. i don't want to write a follow-up article to this one that i wrote... <a href="http://www.forbes.com/sites/kaipetainen/2011/11/20/is-public-safety-first-at-uc-davis-campus-police-must-put-public-safety-first/" rel='nofollow'>http://www.forbes.com/sites/kaipetainen/2011/11/20/is-public-safety-first-at-uc-davis-campus-police-must-put-public-safety-first/</a> in the name of journalism and integrity, i don't want to be a hypocrite.
genetracy
Sat, Feb 18, 2012 : 11:21 p.m.
Boy, the "Harvard of ther Midwest" is relly stepping in it these days. Are they so concerned with their delusional image of themselves that they are willing to resort to crimianl behavior? Child porn, possible cover-up of a murder,....what else is going on over there we do not know about? "Outside investigators" will not find anything, becuase they are hired by the university to paint a pretty picture. I am no fan of the Feds but perhaps the FBI should be called?
Sesame45
Sat, Feb 18, 2012 : 9:35 p.m.
I wonder how this incident came to AA.com's attention. There's no way that AA.com FOIA'd every police report since 2008, looking for something to write about. FOIA takes time and there are probably thousands of reports. I hope AA.com doesn't have somebody at the police department selling them information. That would be scary.
trespass
Sat, Feb 18, 2012 : 11:15 p.m.
Why do you assume anyone would have to pay for a leak. All you have to do is make people feel safe and the stories will come pouring out of the University.
pu2um
Sat, Feb 18, 2012 : 9:15 p.m.
@Jack - Yes, Coleman, and her cohorts, would readily call police...on whistleblowers, but not on wrong-doers and possible criminals. Her administration has routinely abused its police powers to squash anyone with information that is potentially embarrassing to UM, while ignoring those who commit real offenses. @Kai Petainen - Agreed. Somehow a2.com has acquired new found courage. @trespass - I heartily agree that Coleman should step down. The sooner the better.
15crown00
Sat, Feb 18, 2012 : 4:59 p.m.
Does this outfit not know how to do things the right way? Another coverup gate in the works/ M.S. Coleman it's time to fire some of the med school honchos.
UtrespassM
Sun, Feb 19, 2012 : 4:34 a.m.
Need a professional house clean.
genetracy
Sat, Feb 18, 2012 : 11:23 p.m.
Colemsan should resign first. A new university president is in order.
Joe_Citizen
Sat, Feb 18, 2012 : 8:28 p.m.
There is more dark story's at the U, just no one wants to talk about it.
trespass
Sat, Feb 18, 2012 : 5:44 p.m.
Its time MSC gracefully retired and let the Regents do the rest of the firings
Sallyxyz
Sat, Feb 18, 2012 : 4 p.m.
"The family's attorney made a claim of medical malpractice, the hospital offered compensation and the family accepted it, Fitzgerald said. The hospital's review found that the patient was probably moved out of intensive care prematurely, he said. Fitzgerald said he didn't know whether changes were made at the hospital after the incident." All kinds of issues raised in this article. Why was the patient moved out of intensive care prematurely? Because they were a Medicare patient (79 years old) and reimbursements are low? I'd like to hear details about what led to this decision. Scary. If the patient had remained in intensive care, then the increased monitoring would have likely informed staff when the trach tube was removed. "Investigators executed search warrants on the security captain's computer and email account, seizing some documents and other items. AnnArbor.com has filed a Freedom of Information Act request with the university, seeking a copy of the police report. Prosecutors said they no longer have a file on the case because the records were purged." Records from 2008 were purged? Records from only four years ago have been purged? I seriously doubt this is true. Police records are kept a lot longer than that.
newsboy
Sat, Feb 18, 2012 : 3:46 p.m.
The only way to find a story is to FOA one. You never even have to leave comfort of your own office. If you think you have found something, why are you reporting it before the authorities have had time to investigate? When will someone pull the life-support on aa.com and throw it across the room? I won't tell; Shuu.
hmsp
Sat, Feb 18, 2012 : 3:36 p.m.
@Sciomanone1 Would you mind slowing down enough to clean up your grammar and spelling? Maybe read what you've written out loud to yourself? You make some valid points, but it takes a while to decipher what you write.
Sciomanone1
Mon, Feb 20, 2012 : 12:41 p.m.
Thanks for the kind words, I was in my car while writing, as I am now the next time I Will try to use my home computer, most people did get the points of interest of what I write.
nickcarraweigh
Sat, Feb 18, 2012 : 3:19 p.m.
My first thought was the see no-evil, hear no-evil, speak no-evil monkeys. But that maligns monkeys, who are not actually that stupid.
Kai Petainen
Sat, Feb 18, 2012 : 3:11 p.m.
when i saw what i saw... they had problems with communication and i thought it was an isolated incident. (you can see my thoughts at the end of the comments at this link) <a href="http://www.annarbor.com/news/university-of-michigan-regents-call-for-an-external-review-of-six-month-child-porn-reporting-lapse/">http://www.annarbor.com/news/university-of-michigan-regents-call-for-an-external-review-of-six-month-child-porn-reporting-lapse/</a> it was another incident where there was a breakdown in communication, and how 911 calls get routed. i want the hospital to do well, i'm a fan of the hospital.... but someone please fix the problems.
a2citizen
Sat, Feb 18, 2012 : 3:03 p.m.
"... One of her daughters was in the room, sleeping..." And yet the hospital paid off the family.
a2citizen
Sun, Feb 19, 2012 : 5:09 p.m.
That's not the conclusion I came to. But since you brought the subject up...
Matt Cooper
Sun, Feb 19, 2012 : 4:29 p.m.
Which means what? Guilt? Hardly.
The Black Stallion3
Sat, Feb 18, 2012 : 2:49 p.m.
Lots of bad things going on in Ann Arbor medical it seems.......time for an external investigation and this should create some job openings.
Sciomanone1
Sat, Feb 18, 2012 : 2:57 p.m.
Yes, but they say for years that it separate what goes on at the Medical center, so the parents would never find out.
Sciomanone1
Sat, Feb 18, 2012 : 2:38 p.m.
Keep in mind when a police report is made it od called public knowledge and then any one and everyone Will know, even the people that donate millions of $$$ and they do not want to miss out on their donated $$$ so they pay people off for their cover up.
trespass
Sat, Feb 18, 2012 : 2:46 p.m.
It also goes on your Clery Act statistics and parents may begin to realize that UM is not as safe as they want you to believe.
Ron Granger
Sat, Feb 18, 2012 : 2:20 p.m.
This reminds me of so many movie plots. Like calling the police in "Stepford", thinking you will get help. Except the "police" are in on it. They reassure you they will look into it. But they won't. They will not write a report. They brush off your concerns. If you dialed 911, you don't even get the police. You're so many layers removed from real police. It almost seems it would take an act of Mary Sue Coleman herself to personally authorize any matter actually being forwarded to real police. Anyone remember the movie Coma? Ann Arbor film students, get busy!
Jack
Sat, Feb 18, 2012 : 6:02 p.m.
And you think Coleman would do it?
Ron Granger
Sat, Feb 18, 2012 : 2:13 p.m.
This is not surprising - there is never just one roach. These people said they wanted to file a police report and were directed to a security clerk. One wonders if he was impersonating a police officer, with a badge and all? Surely they thought they were dealing with the police and someone who would investigate properly and formally - by actually writing a report of findings. The rest of this reads like a soap opera of "we don't need to write a report". I read that as "we don't need a paper trail". The Risk Management department is only concerned about minimizing lawsuits and bad PR. If they think they can keep something quiet without consequence, they will do it. It is becoming apparent that the hospital has a well oiled machine completely under their control which does a very good job at keeping things quiet. I wonder if there is also a culture of fear among the employees that prevents them from speaking out about what they see?
Matt Cooper
Sun, Feb 19, 2012 : 4:28 p.m.
One major problem with your argument, Ron: Ever looked at the UM campus police uniform? Then looked at the hospital security uniform? See, the police uniform badge says police on it, the security badge does not. The police also carry weapons such as pepper spray and usually a side arm. Security does not. The police uniform and the security uniform physically look nothing alike, and it makes me wonder how someone could look at a security uniform that clearly says SECURITY on it and assume they are talking to a police officer. And to trespass, well, his comments come from someone that has never worked in any kind of security field, has never worn a security or police uniform and even as recently as 2 weeks ago wanted to argue up and down that it is a crime in Michigan for anyone other than a police officer to identify himself as 'detective', 'sergent', 'officer', or other titles that signify rank. So his comments about "...use of these titles is simply a form of conceit (we are just as qualified as police officers)." is simply wrong. I know several of the hospital security staff and worked as a security supervisor myself in a local hospital several years ago and know first hand that that is not the mindset, generally speaking, of the hospital security. I wish that people that have nary a clue about what it takes to secure such a facility as a hospital would, at a minumum, please qualify their own remarks accordingly.
Joe_Citizen
Sat, Feb 18, 2012 : 8:26 p.m.
I see it as job security, the pay is so nice at the U, that no one wants to risk that loss, and if you rock the boat, then you will find yourself in the drink. If you can get the drift.
trespass
Sat, Feb 18, 2012 : 2:44 p.m.
One of the problems with identifying security guards from police is the use of ranks by the security guards. When you introduce yourself as captain or detective seargent people will assume that means you are a law enforcement officer. If you use security officer, security supervisor, security director there would be less confusion. The use of these titles is simply a form of conceit (we are just as qualified as police officers).
sh1
Sat, Feb 18, 2012 : 1:55 p.m.
I get the feeling reporters are digging to keep the original story alive. It's the culture of the new way we do news.
Kai Petainen
Sat, Feb 18, 2012 : 3:34 p.m.
this is not the norm for the ann arbor news. if you look at their history, then they have been incredibly pro-UofM and they seem to act as the pseudo marketing department for the university. there's nothing wrong with that, but ann arbor.com said very little with respect to bad news and the university. even when my incident happened, they said very little and they would censor a lot of the stuff that i said (even though i had FOIA documents to support my comments). something has changed at annarbor.com where they are now servicing the community and providing a valuable service to those of us who live in ann arbor. i'm sure they are fans of the city and of the university, but they are trying to serve a calling that is higher than that. in the long run, i think the work that the reporters are doing will help improve ann arbor and improve the university. it's important work, but it is painful work.
Stanthepotter
Sat, Feb 18, 2012 : 1:54 p.m.
I think we all missing the point here, it's about the U of M s lack of reporting crimes or possible crimes that get told to their police dept. or security force. They think they are only accountable to them selves at best. They are public university, teaching by example to the students that go there that they are above the laws and standards that govern the rest of us. I always say tell the REAL police not some bought and paid for dept of the U of M. They( the U of M) does not have the citizens "best interest " in their minds only whats good for the U of M
Sciomanone1
Sat, Feb 18, 2012 : 1:41 p.m.
This is common for the u of M Medical Center to pay off patients or their family, they have been doing it for years so when there is a cover up or they are at fault, so it is not made public knowledge, they put a stop to it so it does not make the news by a police report.
Matt Cooper
Sun, Feb 19, 2012 : 4:18 p.m.
And you assume that because they settle a lawsuit it must mean they are guilty? Settlements mean nothing of the sort. Often times, businesses etc., will settle lawsuits simply because even if they win they will have spent more money defending it that they would if they just offer a settlement and walk away.
trespass
Sat, Feb 18, 2012 : 1:37 p.m.
I had a patient like this who had cancer of the throat and I had been called the day before because she had pulled out the trach, despite the fact that she had been in cloth restraints, and the nurses could not get it back in. I had to get a rigid bronchoscope and force it through the cancer blocking her airway in order to save her life. I ordered that she be put in leather restraints (a locked leather strap that ties her hands down to the bed). The next day I came on rounds and she was still in cloth restraints (I was with my brother who is also a doctor). My brother got mad at me because I made the nurse feel bad about not following my order to put her in leather restraints but I was more concerned that I did not want this patient to die unnecessarily because the nurses did not want to have to explain why grandma was locked up. All people involved in the care of patients need to be willing to learn from their mistakes, not cover them up. Without that we will continue to make unnecessary mistakes and patients will die. There needs to be a real change of culture at the UM Hospital.
julieswhimsies
Mon, Feb 20, 2012 : 3:33 a.m.
That is a very broad assumption to make, Doc.
julieswhimsies
Mon, Feb 20, 2012 : 3:32 a.m.
I was asked by a "certain local hospital" to accept a settlement in lieu of a lawsuit...and I had to sign a gag order. Sometimes patients...even those who are fighters accept these settlements and sign these gag orders because they want the whole thing to just END.
Matt Cooper
Sun, Feb 19, 2012 : 4:16 p.m.
Leather restraint might well have been the standard of care in the 1960's, but in 2012 they are not used simply for a patient that is known to pull on IV's, etc. They are pretty much only used on combative patients that are known to try to fight and/or injure themselves or others. Secondly, doctors don't just "order" nurses to place leathers on a patient. There must be a written order and certain prerequisites must be met and be present before leathers are considered.
Sallyxyz
Sat, Feb 18, 2012 : 4:05 p.m.
About 200,000 deaths per year in the US are attributable to medical mistakes and hospital acquired infections. I'd like to see a report specifically for the UM hospital showing their portion of these statistics. Where is that available?
Michigan Man
Sat, Feb 18, 2012 : 2:30 p.m.
Trespass - Like the sound of your comments! I too have a healthcare background = administrative side of 40+ years in academic medical centers and community hospitals in the Ann Arbor, Detroit and Chicago locations. Protecting patients and monitoring all aspects of healthcare are where things really start - corrective action, in the interest of strengthening the provision of healthcare, can then be activated and further monitored. Your "critical" comments are welcome.
Sesame45
Sat, Feb 18, 2012 : 1:18 p.m.
So the patient had a history of pulling out her trach tube. If she pulls out this trach tube, she dies. She is found dead with her trach tube pulled out. Nobody was charged with anything criminal, so the family starts thinking along malpractice lines. The malpractice suit was because she was moved out of the ICU too early. The family got paid. But by all means, let's skew this into a witch hunt.
julieswhimsies
Mon, Feb 20, 2012 : 3:25 a.m.
This person has a history of pulling out trach tubes. Who is WATCHING these people?! Should there not be an alarm designed for this device?!
trespass
Sat, Feb 18, 2012 : 11:11 p.m.
@Sesame45- We will never know whether there was a crime because Hospital security did not perform or document a scene investigation and even if they did they are not trained to do a scene investigation. That is why any death that could be the result of what is called a medical misadventure or a crime should be reported to the Medical Examiner. Now it is problematic because the Medical Examiners office has been moved to the University Hospital. ME offices should be independent of hospitals because they are sometimes asked to investigate those hospitals.
Sesame45
Sat, Feb 18, 2012 : 9:23 p.m.
@trespass: I did read the story. My comment does acknowledge that the first response was an investigation into criminal activity, and then malpractice. I am not blaming the victim at all. My point is, there was no foul play, so why the uproar? This article just says "There could have been a crime! There wasn't. But there could have been!" Also, unless you were present, saw the scene, read all the documentation, saw the patient and were familiar with her history, and knew precisely what equipment was in the room and exactly how it was used that night, you may not be in a position to speculate about forensic details.
johnnya2
Sat, Feb 18, 2012 : 4:41 p.m.
@trespass, If a person VOLUNTARILY pulls pout their trach they are not a victim by any definition of the word. IF the hospital forced them to keep the tube in, THEN she would be a victim.
trespass
Sat, Feb 18, 2012 : 1:26 p.m.
You are blaming the victim, which is prohibited under AA.com guidelines but if you read the story the families first response was that there was foul play not negligence.
average joe
Sat, Feb 18, 2012 : 1:03 p.m.
It appears that there is quite a bit of finger pointing in this case too.
trespass
Sat, Feb 18, 2012 : 12:36 p.m.
A tracheostomy tube is secured in place with a cord that runs around the back of the neck. It is a pretty tough cord and it is normally cut with a pair of scissors when the tube is removed. The tracheostomy tube cannot be thrown across the room unless that cord is somehow broken. If the patient did that themselves the cord should be broken. There should also be some evidence, such as a bruise or red line around the back of the neck, as a result of pulling hard enough to break the cord. These are the kind of things that would have been documented by a scene investigation by the police or the medical examiner's office. Even if the hospital thought the patient removed the trach herself, they had to know this would end up in court one way or another. That is why it is mandatory that they report this type of death to the medical examiners office who then may notify the police. Once again, Hospital security along with the General Counsel's Office decided to handle this as a liability issue rather than a crime. The Hospital also decided not the report the death of Molly Ripley to the Medical Examiner's Office, even though she showed obvious signs of abuse when she was transferred from a nursing home. <a href="http://www.annarbor.com/health/renaissance-community-homes/?cmpid=RSS_link_health">http://www.annarbor.com/health/renaissance-community-homes/?cmpid=RSS_link_health</a> UMHCS is failing in its duty to report to proper authorities deaths and crimes that must be reported and patients are endangered by that failure. We now find that the Hospital and the University were warned earlier that they must report alleged crimes to police but they did not learn their lesson and it happened again in the child porn case. How many more failures to report have happened? They all add to the culpability of those involved.
Matt Cooper
Sun, Feb 19, 2012 : 10:30 p.m.
Actually, SEC, I think you are thinking of an endotracheal tube, or ET tube, which is significantly different from a tracheostomy. The ET tube is a plastic tube that is inserted externally into the airway as a means of oxygen delivery and is indeed secured by an inflation baloon as well as with 1/2 inch cloth tape, attached to the tube and it ties around the back and side of the patient's head. A tracheostomy is an airway that is placed into the airway via a small incision through the neck. It is held in place by an internal baloon that inflates and acts as an anchor along with a two-piece soft spongy foam strap that is secured on either side by spongy foam straps with a velcro closure.
SEC Fan
Sun, Feb 19, 2012 : 8:07 p.m.
Actually, as recently as Nov 11, they used tape, not a velcro tie, at UM. (They did it with my spouse).
Matt Cooper
Sun, Feb 19, 2012 : 4:10 p.m.
Barb's Mom is absolutely correct. I have worked in an ICU for nearly 11 years and we have always used trach ties that are made of a soft, spongy material that is secured with a velcro enclosure at the sides of the neck. And yes, it is totally possible (I might even say probable) that the patient pulled out the trach by herself. I myself have seen this happen. In cases of pt's who have a history of pulling on tubes, IV lines etc., we employ a variety of devices to try to assure this doesn't happen, but if the family requests that these devices be removed on the promise that they stay in the room with the patient we will sometimes honor that request. Finally, yes, a trach can be removed by a patient (even a delirious one) and thrown across the room without any assistance.
Barb's Mom
Sat, Feb 18, 2012 : 10 p.m.
@trespass- how long ago did you see the trach ties? I have worked with the velcro ones since the 1990's. You said "@Johnny- your statment is absurd. Usually patients who pull our vital life saving equipment like trach tubes do it while they are confused. Mostly at night when they are waking from sleeping". In my reading of the article, the lady died during the night with a family member in the room. Maybe the family requested that she not be restrained and she pulled the tube out and threw it across the room while the family member slept.
trespass
Sat, Feb 18, 2012 : 5:07 p.m.
Thank you aaMD. It has been a while since I used a trach tube and this story was from 2008. It seems like a design flaw for someone with a history of pulling at their trach tube. It sounds like there should be an alternative for patients who are completely dependent on their trach tube and may be in danger of pulling it out. In this case, multiple people from the hospital said that the death was "suspicious" so there must have been something odd about the case.
aaMD
Sat, Feb 18, 2012 : 3:28 p.m.
The above description of a trach tie is incorrect. The trach ties used by modern hospitals DO strap around the back of the neck, but do so by a velcro connection so they are easily removable for cleaning secretions, blood, etc.
UtrespassM
Sat, Feb 18, 2012 : 12:34 p.m.
The child porn is one case. The patient suspicious sudden death is another case. The key problem is the culture, the covering up.
Craig Lounsbury
Sat, Feb 18, 2012 : 1:03 p.m.
as Sgt Schultz would say, "I know nothing! I see nothing!"
utownie
Sat, Feb 18, 2012 : 12:03 p.m.
News flash -- sometimes really sick people die in hospitals! The Prosecutor did not charge anyone. The Regents are looking into how to improve procedures. 99 years ago I heard a patient died under suspicious circumstances in old main hospital. Please investigate for us.
trespass
Sat, Feb 18, 2012 : 6:54 p.m.
@Johnny- your statment is absurd. Usually patients who pull our vital life saving equipment like trach tubes do it while they are confused. Mostly at night when they are waking from sleeping. We are not talking about a patient who makes a concious decision to stop treatment.
johnnya2
Sat, Feb 18, 2012 : 4:38 p.m.
"If she was completely dependent on the trach tube and she had previously tried to pull it out, she should have been adequately monitored or restrained. " WOW! That is the scariest statement I have ever heard in my life. A patient does not have the RIGHT to pull out their own trach tube? They do not have the right to decide what care they want? YOU are allowed to force her to take treatment she does not want? Maybe next they will RESTRAIN women and force them to have c-sections because they are more profitable. They will MONITOR to make sure mothers are breast feeding and not giving babies that evil bottle. RIDICULOUS
Dcam
Sat, Feb 18, 2012 : 1:21 p.m.
I've seen pictures of the old medical building on campus, and right behind it is a graveyard with about twice the footprint. Not a comforting thought.
trespass
Sat, Feb 18, 2012 : 1:13 p.m.
I believe she was getting ready to leave the hospital so she was not in imminent danger of dying from her cancer. If she was completely dependent on the trach tube and she had previously tried to pull it out, she should have been adequately monitored or restrained. Perhaps she needed to stay in the ICU or intermediate care or have a vital sign monitor that could be seen at the nurses station.
trespass
Sat, Feb 18, 2012 : 12:38 p.m.
I am glad that you are not the Hospital's quality control manager. Ignoring mistakes is why they get repeated. The police tried to get charges against the security captain for obstruction of justice. That tells you just how serious this was.
UtrespassM
Sat, Feb 18, 2012 : 12:38 p.m.
How old are you? "99 years ago I heard...." This is just another case of covering up.