Homicide ruling in ED may have chilling effect
Even though criminal charges will not be brought against emergency department (ED) workers following a coroner's ruling that a patient's heart attack death was a homicide, the case could have a chilling effect on health care workers across the country. Observers say the case could make ED staff more fearful of second-guessing and interfere with risk managers' attempts to encourage open communication.
The Lake County, IL, State's Attorney's Office announced recently that it will not pursue criminal charges against Vista East Medical Center in Waukegan, IL, or any staff member for the heart attack death of Beatrice Vance on July 29, 2006. Matthew Chancey, JD, chief of the criminal division, released a statement saying, "After a careful review, it is the determination of this office that there is insufficient evidence to support the filing of criminal charges against any person or institution."
Vance, 49, died of cardiac arrest in the Vista East ED after a wait of approximately two hours. A coroner's jury determined the death was a homicide. The jury pinpointed Vance's arrival at the hospital at 10:15 p.m. and determined that she was unconscious when a nurse called her name for treatment at 12:25 a.m.
A deputy coroner said the heart attack was caused by a blocked artery and contributing factors were delayed and inadequate treatment. After the coroner's inquest, Chancey headed an investigation to determine whether criminal charges were supported by the evidence and stated that being able to show recklessness was the major hurdle in filing criminal charges.
Vista Health spokesman Cory Savage issued a statement saying the company would not be making any comment. The organization has consistently declined to comment on the case and cited privacy laws.
Ruling still damaging
The lack of criminal charges is not surprising because the whole premise of the homicide ruling was flawed, says Patricia Iyer, MSN, RN, LNCC, president of Flemington, NJ-based Med League Support Services, a legal nurse consulting firm specializing in malpractice and personal injury cases. However, in terms of the effect on health care workers, the damage already has been done, she says.
Simply raising the specter of criminal charges such as homicide or murder can have a strong effect on people even if the charges are never brought in the end, she says. This case will have a chilling effect on the recruitment of nurses and physicians for ED work, Iyer predicts, and it will discourage staff from speaking freely for fear of drawing fire.
"This is a real setback for risk management and the effort to convince people that they can speak freely and openly about adverse outcomes, that they should speak up without fear of retribution," she says. "If someone thinks they might actually be charged with homicide, that's a bigger deterrent to speaking up than anything else we've addressed, like losing their jobs."
Homicide ruling said an overreaction
Given the circumstances of the case, a medical malpractice allegation would not have been surprising or unusual, Iyer says, although that allegation doesn't mean the ED staff did anything wrong. But the homicide ruling was an overreaction by local authorities and not supported by the evidence, she says. Iyer theorizes that the homicide ruling may have been the result of a coroner's jury with members who wanted to send a message about long waiting times or impersonal care in the ED.
Local authorities may have been trying to make a point also, says Gregory L. Henry, MD, FACEP, risk management consultant for Emergency Physicians Medical Group in Ann Arbor MI. He says any sort of criminal charges were a stretch, and a murder charge never would have stuck. That charge requires intent, which was absent in this case, he says.
Needed: Proof of recklessness
Even a lesser charge would require proof of recklessness, which Henry says would be difficult to prove against ED staff. Henry says the local authorities may have known this all along and just wanted to scare the hospital staff with the threat of criminal charges. "If so, I'd say a job well done. People are going to look at this and say, 'Why the hell am I doing this for a living?'" he says. "If Waukegan, IL, has trouble finding doctors and nurses to staff their EDs in the coming years, they should go to the coroner and ask him why. When clinical decision making becomes a criminal event, we're treading on very thin ice."
Could a long wait in the ED ever cross the line from "unfortunate but unavoidable" to criminal recklessness? It's possible, Henry says, but authorities would have to prove an egregious case of misconduct rather than a debatable case such as the one in Illinois. "If you have a patient lying on the floor turning blue and you take someone with a cut finger first, maybe you could make a criminal case out of something that bad. But it's never that clear," he says. "I once had 13 kids on a bus hit by a cement truck, and I was the only doctor in the ED. Someone was going to be 13th to be examined that day."
Iyer notes that, aside from the inappropriateness of the homicide ruling, there may have been missteps by the hospital that should be noted by risk managers. (See article, at the end, for advice on how risk managers can respond.)
"From a pure risk management standpoint, what is concerning is that there was a family mother who was asking for attention for her mother in the ED, and she couldn't get any help," Iyer says. "The usual standard is to make an assessment of people in the waiting room at intervals, to determine if anyone has become unstable after the initial assessment and now needs treatment. From a liability standpoint, the issue is whether she was given an appropriate level of triage when she came in and, secondly, what was her status in the waiting room when she should have been checked periodically."
Don't avoid difficult patient
Henry does caution about one scenario that could lead to criminal charges in the ED. If staff are familiar with a patient who is consistently difficult and disruptive, and they intentionally avoid examining or treating the patient for that reason, any resulting harm could meet the standards for reckless conduct and criminal charges, he says.
"Long waits are not criminal," Henry says. "But if you always put Mr. Jones at the end of the line because he's been in the ED 10 times this month and he's always a pain to deal with, you're going to be in trouble if he shows up one day with a headache that's really a subarachnoid hemorrhage."
Sources
For more information on the risk of homicide charges related to emergency care, contact:
- Gregory L. Henry, MD, FACEP, Risk Management Consultant, Emergency Physicians Medical Group, 1850 Washtenaw Ave., Ann Arbor MI 48104. Phone: (734) 995-3764. Fax: (734) 995-2913. E-mail: [email protected].
- Patricia Iyer, MSN, RN, LNCC, CLNI, Med League Support Services, 260 Route 202-31, Suite 200, Flemington, NJ 08822. Telephone: (908) 788-8227. Web: www.medleague.com.
Review policies on emergency triage
The homicide ruling related to an emergency department (ED) death at Vista East Medical Center in Waukegan, IL, should be a wake-up call for risk managers, says Patricia Iyer, MSN, RN, LNCC, president of Flemington, NJ-based Med League Support Services, a legal nurse consulting firm specializing in malpractice and personal injury cases. Even if the homicide ruling was an overreaction, she says, there still are lessons for risk managers.
Iyer makes these recommendations:
- Review your policies regarding periodic assessments of patients waiting in the ED. Do not fall into the trap of focusing only on the initial triage of incoming patients.
"From what I saw in the news reports, this woman was complaining of chest pains and other symptoms that would have warranted having her receive treatment more quickly," she says.
- Periodically review medical records from the ED to make sure that the triage policies are being followed. It's one thing to have the right policy and procedure down on paper, but that doesn't mean that staff actually do that every day.
- The ED should conduct its own spot reviews to confirm that the condition of patients in the waiting room is being assessed and updated regularly.
- "It is the unfortunate nature of an ED that the unit can be empty and then patients converge on it all at one time. That adds to the stress and the challenge of triage," she says. "The ED manager or other leader in that unit should confirm that triage update is being done, on a real-time basis, in addition to any record review done at a later date."
- Emphasize to staff that the Vista East Medical Center homicide ruling was an isolated incident and that such an outcome is very unlikely.
"This can be the biggest challenge on this issue," she says. "We've got to reassure people that they can and should speak up without fear. We've made a lot of progress in this area, but just one case like this can undo a lot of your work."
Even though criminal charges will not be brought against emergency department (ED) workers following a coroner's ruling that a patient's heart attack death was a homicide, the case could have a chilling effect on health care workers across the country.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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