HOUSTON -- The death of a loved one is unbelievably hard to bear, especially when it is sudden and unexpected. It is perhaps even harder when the patient is in the hospital for a supposedly minor condition.
When something like this happens, the first place people often look is at the patient’s medical record. This is the official history of your health and treatment.
However, a three-month KHOU-TV investigation has found evidence of what may be a national problem when it comes to medical records. It seems that some nurses, doctors and administrators have concealed, faked and even destroyed these documents when trouble happens.
Linda Carswell says she knows all about it.
She claims she often wakes up in the middle of the night, trembling and alone. She thinks about her husband, Jerry, and the 33 years of romance and marriage they shared together.
“(I knew) after the first kiss, I guess,” Carswell said. “He was definitely a romantic.”
As a high school coach, Jerry Carswell helped mentor students and develop some of them into professional athletes, like NFL star Bert Emanuel, who would later call Carswell the “best coach ever.”
But one morning, things took an abrupt turn.
“He woke up and told me that something was wrong,” Carswell said.
The couple visited Christus St. Catherine Hospital for what seemed like a minor problem to them.
“They diagnosed it pretty quickly. It was a kidney stone,” Carswell said.
Jerry decided to stay at St. Catherine’s for a few days, hoping for the stone to pass. Eventually, he sent his wife home.
“(He said) there's no reason for you to stay here. I’ll be fine,” she said.
“The nurse looked at me and said, ‘your husband is dead.’ Just like that,” Carswell recalls. “I said, ‘What? What happened? What happened?’”
Rickey Dorriety says he is asking the same question now.
His wife of more than 30 years, Melissa, checked into Christus St. Catherine for diabetes problems. He says he, too, saw no signs to make him worry.
“We were told Melissa was going home the next morning,” Dorriety said.
The next morning, he and his son stopped at the bagel store so they could deliver breakfast to Melissa.
When they walked into her room, Dorriety says he and his son discovered something horrible.
“I said, ‘Come on, wake up sleepy head.’ And nothing happened. She had a tear running out of her right eye,” Dorriety said.
Soon after, Melissa Dorriety died.
“She won't be able to hold her future grandson,” Dorriety said. “That...that hurts so bad.”
Dorriety filed a lawsuit against Christus St. Catherine to look for answers. But after his attorney subpoenaed for Melissa’s medical documents, Dorriety's attorney claims an important document came up missing.
It was the nurse’s worksheet showing Melissa’s condition, including the original medical notes made about her.
Nearly one year later, after KHOU-TV contacted Christus St. Catherine to ask about both the case and the missing document, the missing worksheet finally showed up.
“It’s a hospital system that apparently thinks they can get away from being held accountable,” Dorriety’s attorney Jim Perdue said. “That may be one thing in an isolated legal case, but not when you see it happening again and again and again.”
There is also the case of Sharon Rogers.
After she died at Christus St. Catherine, a malpractice suit was filed. But a section of her vital sign records during critical hours of her care could not be found.
We asked Pat Iyer, a former nurse and an expert consultant on medical records, about the cases. She says the hospital should know to preserve and maintain all medical related documents after an unexpected death.
“That information should be saved for future use and looked at,” Iyer said.
KHOU also found evidence of similar accusations regarding various hospitals around the country. These hospitals have no affiliation of any kind to the Christus organization.
In one landmark case, a surgeon in New Jersey removed the wrong lung from a patient. He then changed the medical record afterwards, so it appeared he had in fact taken out the correct lung.
In fact, New Jersey has criminalized altering or destroying medical records, but in Texas, there is no such law.
KHOU also discovered the Texas Department of Health could not find a record of investigating a single allegation related to concealing or tampering with medical records at any hospital in the state.
The Department of Health declined an on camera interview with KHOU to explain more, but did write this in an email: “We have not had any formal regulatory investigations about that topic in recent history.”
It makes Linda Carswell feel like the system is set up to protect hospitals, not patients.
“I knew something had happened that they weren't telling me,” she said about the hospital.
She also says she wanted the public medical examiner to do an autopsy on her husband’s body, but was told by the hospital that the medical examiner declined her request.
“I believe Harris County would have done the kind autopsy that would have looked for reasons for his death,” Carswell said.
Carswell agreed to let Christus have another hospital do the exam instead, but she says later she discovered that other hospital was also owned by Christus. She also didn’t get a complete autopsy like she wanted.
She also claims that a sample of her husband’s body fluids disappeared, after she says she asked for them to be saved. She says they were fluids which could have been tested.
Next, she says she learned that Harris County officials could not find any record of Christus ever calling them to perform her husband’s autopsy.
The worst news, though, came nearly two years after Jerry had been buried.
“They had kept, secretly, Jerry’s heart,” Carswell says.
After Carswell filed suit, under sworn questions, the autopsy doctors said they had removed her husband’s heart and stored it in a container.
But when the questioning turned to who knew about the decision to remove the heart, the doctor admitted that they didn’t tell Carswell they were taking out the organ.
“I don't recall telling anyone,” said the doctor.
Recently, a judge issued a rare $250,000 sanction against Christus St. Catherine’s, ruling that the hospital “improperly concealed the heart tissue of Jerry Carswell in a Christus pathology laboratory.”
The sanction further said the hospital also concealed blood samples, and determined that Linda Carswell’s case against the hospital had been “severely prejudiced” due to the “improper concealment of critical physical evidence.”
The Christus health organization and its attorney declined an on-the-record interview with KHOU-TV, but did give this statement:
“We are deeply saddened whenever a family loses a loved one to disease and illness. Our hospital is committed to fulfilling our mission and serving our community by providing high quality, compassionate health care to our patients. While we wish we could fully respond, we think it best to handle such delicate, complex matters in an appropriate venue where the facts and full context can be carefully deliberated.”
Republished from Tuesday, May 12, 2009 at 10:27 AM CDT