Blaming the Hospital, a Widow Turns Activist: She Says the Staff Was Unresponsive
Tuesday, July 21, 2009
When a hospital stay ends badly, there's not always agreement on what went wrong.
Though the hospital that treated Vincent Hereford during his final illness does not acknowledge medical error, it does admit that it could have done some things differently. And since his death, his wife, Michelle, has become a crusader for patient safety.
The story began in January, when Vincent, a retired radiation control instructor for Northrop Grumman, developed a bowel problem and flew from his home near Richmond to the University of Michigan Medical Center, where he underwent surgery. (Vincent had struggled with leukemia for 18 years, and his oncologist had moved to Michigan.)
Michelle, a hospital administrator who is trained as a clinical nurse, saw her husband's fever spike during his recovery and suspected that poisonous fecal material might be leaking from his bowel into the rest of his body. But she said the hospital's medical staff was unresponsive and declined to order a CT scan of Vincent's abdomen.
After several days, with Vincent being seen by a new doctor every day, a CT scan was done and a doctor confirmed Michelle's fears and began treatment. Vincent was flown to the Medical College of Virginia in Richmond, where he died nine days later, on Feb. 19. One of the causes of death was sepsis -- poisoning from the spread of bacteria or other toxins. Vincent Hereford was 44.
Michelle filed a complaint with the University of Michigan Medical Center, claiming that the perforation in his bowel was diagnosed too late. The hospital's chief risk officer, Richard Boothman, apologized to Hereford in a letter for the "additional stress" she experienced during her husband's hospitalization. He acknowledged that the hospital staff "could have communicated better." Boothman did not say the staff made a mistake in his treatment.
"It was a canned letter," Hereford said. "It was not an admission, and it wasn't a denial. They're minimizing their risk."
After Vincent's death, "I sat still for a while," she said, tending to her children, ages 13 and 15. Now, she says, she is speaking out because she hopes it will bring about some change, however small. When mistakes happen in hospitals, she says, "it's not because they don't have bells and whistles and technology," she said. "It's because nurses become robots and they don't listen."
Boothman said in an interview that the hospital "closely examined" whether there was any delay in diagnosing the perforation. The conclusion was no: Vincent was at a great risk for surgical complications given his cancer, and his doctors felt they could not operate again until they had more evidence.
The problem, he said, was that Hereford was not in the loop. "Nobody sat down and said to her, 'This is what we're going to do and this is why we're doing it,' " Boothman said. "Mrs. Hereford happened to be very prescient."
In addition to pledging to communicate better with patients, the hospital made another change: The attending surgeon who admits non-emergency patients will continue to manage those cases, as opposed to giving that responsibility to a different doctor each day. "Patients will see the same face every day, [a professional] who is accountable to them," Boothman said.
At Boothman's urging, Hereford has agreed to work with the hospital and chronicle her experience for his staff.
"I said, 'Regardless of whether your concerns about the quality of care are well-founded or not, we are deeply interested in hearing your story,' " Boothman said. "The perception that you're not getting good care can be just as important as reality."