When Joachim Minor left the operating room at the Navy hospital in Oakland in June, doctors there had reason to be satisfied. They had successfully removed a perforated gall bladder from the retired machinist's mate, and all that remained to be done was routine post-operative care.
Minor was taken to an intensive care unit, and placed on a ventilator. Blood tests were ordered. Then the doctors in charge were called away for other emergency work in the shot-staffed hospital.
Two hours later, Minor was found lying unattended, in critical condition. A blood test, which could have warned doctors of his decline, had never been performed. He died the next day.
In a report released last month, the Navy's top investigator concluded that although Minor had received "adequate medical care" an "unfortunate failure of communication between the surgeon and the anesthesiologist resulted in a lapse in obtaining an important test."
That language is as close as the report by Navy Inspector General Rear Adm. Stanley Anderson comes to blaming the Navy for any of seven widely publicized deaths at the hospital in the past 18 months.
The report did, however, discover substantial staff and equipment shortages and morale problems at the hospital and said the deficiencies threaten patient care."
The shortages contributed to most of the other deaths, the report said, but were not directly responsible for them.
The investigation at the Oakland hospital, one of the Navy's largest and most highly regarded facilities, was sparked by a formal complaint by one doctor that the shortages created a condition "severely deleterious to patient care."
The report disputes the charge, but concedes "it is clear that certain shortages existed which could have been avoided or minimized by more vigorous management."
The numbers of doctors, particularly anesthesiologists, and medical corpsmen at the Oakland facility were down sharply compared to recent years, the report found. It noted that the decreases reflect overall Navy cutbacks in hospital staffing.
"The reductions in hospital staffing affect health care delivery and impact on training," the report says. While the hospital's staff physicians did not think care had suffered greatly, "residents . . . clearly felt that patient care was inadequate in some instances."
The report's conclusions with regard to the equipment shortages were similar.
"There is general agreement among the anesthesiology staff that equipment during the past year has been inadequater for patient care needs," it said.
"Specifically, there were insufficient numbers of ECG monitors [brain monitors], pressure monitors, defibrilators [heart stimulators], and functioning anesthesia ventilators."