Hospital To Pay Fine In 2 Deaths

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St. Raphael Agrees To $250,000

by Jack Dolan
The Hartford Courant

November 1, 2002

In a record settlement between a Connecticut hospital and state regulators, New Haven's Hospital of St. Raphael agreed Thursday to pay $250,000 to end the state's investigation of a case involving the deaths of two patients last winter.

Both women suffocated in January because the oxygen mask used during a routine heart procedure was mistakenly hooked up to a source of nitrous gas. Two other patients also accidentally got the potent anesthetic instead of oxygen before the error was discovered, but both survived.

"The department feels that this payment is appropriate given the egregious nature of our findings," said William Gerrish, spokesman for the state Department of Public Health. "In addition to the monetary payments, this agreement imposes terms to improve patient care and protect patient safety."

The civil penalty is more than twice the previous record for a hospital in the state, which was $100,000 paid by Hartford Hospital after a fatal accident involving a dialysis machine in 1988.

There is no restitution for the families in the state's agreement with St. Raphael's, but survivors of both women have retained medical malpractice attorneys.

Hospital spokeswoman Cindy von Beren said that an out-of-court settlement has been reached with one family, and that negotiations with the other family and their attorney are underway.

"It's a worthy thing to try to show hospitals that there will be consequences for what is one of the most horrendous acts of negligence that ever occurred in the state," said attorney Michael Koskoff, who represents the family of Joan Cannon, the second woman to die.

"But the amount involved in this settlement isn't at all enough to serve as a deterrent. It won't solve the dangerous problem of negligent care," Koskoff said.

Doris Herdman, 72, of Southington, and Cannon, 68, of Wallingford, died in January during cardiac catheterization, a procedure which involves inserting a line through an artery in the groin and guiding it into the heart to detect, or clear, blockages.

Herdman's death originally was attributed to her age and frail health, and put down as "natural" by an assistant state medical examiner who filled out her death certificate.

In fact, a hospital technician had mistakenly attached the oxygen line leading from the mask to a tank of nitrous gas. While the nozzle for an oxygen line has special prongs that prevent any other kind of gas tank to be hooked up, one of those prongs was broken off in this case.

Food and Drug investigators could not determine how the break occurred, but don't believe there was any tampering, von Beren said.

The mistake was discovered four days after Herdman's death, when Cannon's oxygen level and heart rate plummeted during the same procedure in the same lab. Hospital staff noticed the faulty hookup after they had spent minutes trying to revive Cannon with even more "oxygen" that was, in fact, the deadly nitrous gas.

The day before Cannon's death, medical staff noticed that two other patients hooked up to the same equipment suffered low oxygen levels and lowered heart rate during their catheterizations, but did not determine the cause of the problem.

But while hospitals are the largest institutions the state health department licenses, they don't necessarily pay the largest fines when things go wrong.

In April, the Weinstein Mortuary in Hartford agreed to pay more than a half-million dollars rather than fight health department charges of price-gouging, product-switching and embalming bodies without the family's consent.

"In the matter of Weinstein, we found that they took deliberate actions against individuals for personal monetary gain," Gerrish said. "What happened at St. Raphael's, while very serious, was an accident. They brought the issues to us voluntarily, and have been very cooperative in implementing remedial measures that will improve patient safety."

In addition to $390,000 civil penalties, legal fees and charitable contributions, the Weinsteins agreed to pay $123,000 in restitution to families allegedly harmed by their practices.