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Deadly errors and politics betray a hospital's promise

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On a warm July afternoon, an impish second-grader named Dunia Tasejo was running home after buying ice cream on her South Los Angeles street when a car sideswiped her. Knocked to the pavement, she screamed for help, blood pouring from her mouth.

Her father bolted from the house to her side. An ambulance rushed her to the nearest hospital: Martin Luther King Jr./Drew Medical Center.

For Elias and Sulma Tasejo, there was no greater terror than seeing their 9-year-old daughter strapped to a gurney that day in 2000. But once they arrived at King/Drew, fear gave way to relief.

Dunia's injuries were minor: some scrapes, some bruises and two broken baby teeth. The teeth would have to be pulled.

"They told me to relax," Sulma recalled. "Everything was fine."

At least, it should have been.

What the Tasejos didn't know was that King/Drew, a 233-bed public hospital in Willowbrook, just south of Watts, had a long history of harming, or even killing, those it was meant to serve.

Over the last year, reports by journalists and regulators have offered stark glimpses of failings at King/Drew: Nurses neglecting patients as they lay dying. Staff failing to give patients crucial drugs or giving them toxic ones by mistake. Guards using Taser stun guns on psychiatric patients, despite an earlier warning to stop.

Over the same period, a team of Times reporters has been systematically examining the hospital. They conducted hundreds of interviews, studied years of malpractice cases and reviewed records of the hospital and its regulators. They looked closely at individual departments and physicians. And, to put their findings in perspective, they consulted outside experts in hospitals and medical care.

The investigation reveals that King/Drew is much more dangerous than the public has been told.

Among the findings:

•  Errors and neglect by King/Drew's staff have repeatedly injured or killed patients over more than a decade, a pattern that remains largely unscrutinized and unchecked. Some lapses were never reported to authorities — or even to the victims or their families. And some people learned of the severity of the failings only by suing or, in several instances, from Times reporters who sought them out to learn about their care.

•  Although King/Drew opened in 1972 with the promise that it would be "the very best hospital in America," it is now, by various measures, one of the very worst. It pays out more per patient for medical malpractice than any of the state's 17 other public hospitals or the six University of California medical centers.

•  Entire departments are riddled with incompetence, internal strife and, in some cases, criminality. Employees have pilfered and sometimes sold the hospital's drugs; chronic absenteeism is rampant; assaults between hospital workers are not uncommon. Despite King/Drew's repeated promises to regulators, the problems have gone unfixed for years.

•  The hospital's failings do not stem from a lack of money, as its supporters long have contended. King/Drew spends more per patient than any of the three other general hospitals run by Los Angeles County. Millions of dollars go to unusual workers' compensation claims and abnormally high salaries for ranking doctors.

•  The hospital's governing body, the county Board of Supervisors, has been told repeatedly — often in writing — of needless deaths and injuries at King/Drew. Recently the supervisors have made some aggressive moves aimed at fixing the hospital. But for years, the board shied away from decisive action in the face of community anger and accusations of racism.

King/Drew, founded in the aftermath of the 1965 Watts riots, has stood for more than three decades as a symbol of justice and political power to many black people in South Los Angeles and beyond. In reality, if not officially, the hospital was established by and for African Americans; the majority of its staff always has been black.

"That hospital means hope to us," said Karimu McNeal, 52, an African American woman treated successfully for colon cancer at King/Drew in 2002. "When you go into the hospital and you see people that look like you and take care of you, it gives you hope for the whole race that we're achieving and doing something."

Mixed with community pride is an undercurrent of concern about King/Drew's standards. For about three decades it has been known by an unflattering nickname, "Killer King." Patients have fled ambulances to avoid it, according to paramedics and one ranking fire official. And police officers say they have an understanding among themselves that, if shot, they will not be taken there.

The Tasejos, immigrants from Guatemala, didn't know any of this the day their daughter was hurt. All they knew was that she needed help.

In the seven hours after Dunia's arrival, the hospital would commit a series of medical errors in treating her, each compounding the one before.

By the middle of that night, the couple were standing outside the pediatric intensive care unit, bewildered and increasingly frightened. Alarms were ringing and doctors were running by. The Tasejos tried to catch the eye of a physician who had reassured them earlier.

"He looked at me," Elias Tasejo recalled. "He kept walking."

Here is an account of Dunia's care, based on her medical records, a state health department investigation, a medical expert consulted by The Times and interviews with her family:

To keep her still during a precautionary CT scan, her 65-pound body was pumped with enough drugs to sedate a grown man.

Paralyzed by the medications, she had to be hooked up to a ventilator to help her breathe. Its settings were wrong; a blood test showed she was being starved of oxygen.

The settings were adjusted to give her more. But inexplicably, an emergency room doctor ordered a trainee physician to pull out Dunia's breathing tube 20 minutes later. No one checked to see whether she could breathe on her own.

For the next two hours, Dunia's nurses failed to monitor her vital signs or breathing, records show. By the time she was transferred to the pediatric intensive care unit, she was flailing from lack of oxygen and calling, "Mama."

The medical resident who admitted her to the ICU was unable to operate a machine to check her oxygen levels, and didn't seek help for at least 15 minutes.

By then, Dunia's heart and lungs had stopped working. Doctors resuscitated her, but later that day she was declared brain dead.

After two days, she was removed from life support.

"This child should not have died," said Dr. Lorry Frankel, chief of pediatric intensive care at Stanford University's children's hospital, who reviewed Dunia's records for The Times. "If she had been taken to any pediatric center that had appropriate policies and procedures in place … she would still be alive today."

Frankel described Dunia's care as "appalling" and "really pathetic."

After her death, a team of doctors took the Tasejos into a room and promised to find out what had killed her.

Elias Tasejo said the associate medical director handed him a business card. He kept it in his wallet for three years, thinking he might hear back. He never did.

"Our daughter is dead," he said earlier this year, "and we have no idea why."

*

Hospital defendersWhat happened to Dunia, and others like her, rarely figures in the public debate over King/Drew. Community activists, who fought so hard for the hospital's creation, are far more consumed with the fear that it could be closed.

When King/Drew is threatened, it is often Lillian Mobley — long the hospital's most visible defender — who takes the microphone.

Last January, she stood facing about 200 people in an auditorium at Grant AME Church in Watts. As cheers of adoration washed over her, Mobley, a thin woman of regal bearing, thrust her chin forward in a characteristically defiant pose.

Moments passed. When the last voice had been stilled, when every head turned her way, only then did she speak.

"The hospital," she said gravely, leaning on a cane, "is being closed piece by piece."

There were murmurs, shouts of dismay.

"We have to stand together to fight this battle," said Mobley, her voice rising. "We have to rise every morning under God's will … to save Martin Luther King."

That meeting, held to protest planned cutbacks at King/Drew, was one of many such gatherings she has addressed over the years.

Strong-willed and fiercely protective, Mobley, 74, is at the forefront of a coterie of African American leaders, most now in their 70s and 80s, who defend King/Drew with the same intensity that they once devoted to the civil rights movement.

To them, it is part of the same struggle.

Some vividly recall how things used to be, when they had to find a ride to the main county hospital some 15 miles away. It was a long trip if you didn't have a car — and most people didn't. "Twenty-five dollars sick" meant you were in bad enough shape to pay for a cab across town.

Many remember the case of Leonard Deadwyler, a black man who in 1966 was rushing his pregnant wife from their home in Watts to County General Hospital (today's County- USC) in Boyle Heights when police stopped him for speeding. An officer approached his car and shot him to death. The shooting was determined to have been an accident, but many saw it as a racist killing.

They also remember how the voters of Los Angeles County, mostly white, refused to pay for King/Drew's construction, forcing Supervisor Kenneth Hahn to find money elsewhere. Even now, threats to trim the hospital's budget revive fears that whites are trying to take it away.

"We see something that we fought really hard for," said Dr. Herbert Avery, 71, an obstetrician who helped plan the hospital and served briefly on its staff. "And now it's being driven down under the ground under the guise that the people out there … they're black and Mexican and they're too stupid to run a hospital and a medical school."

Mobley's group is small, and its members hold no elective office, yet they are the curators of King/Drew's dream. They are often called simply "the Community," reverently spoken, as with a capital C. It is a status they have guarded ever more zealously as the neighborhoods around them have become increasingly Latino.

"If you're going to work at King/Drew, you have to work with the Community," said Dr. Thomas Yoshikawa, chairman of the internal medicine department. "You just can't come in and say, 'I'm the new kid on the block. I'm going to play the game my way.' No, you have to play the game their way."

Defying them can draw charges of racism — even when the transgressor is African American.

In the fall of 2003, members of Mobley's group paced the lawn in front of the hospital, as one bellowed through a bullhorn: "Marcelle Willock, you can't hide. We charge you with genocide."

Willock, who is black and Latina, is dean of the hospital's affiliated medical school at the Charles R. Drew University of Medicine and Science. The protesters contended that she had not done enough to protect and support key programs.

While racial politics sometimes play out on its expansive front lawn, inside the hospital, King/Drew's legacy is on display.

In the lobby are prominent portraits of King; his wife, Coretta; and local political dignitaries posing beside former Presidents Clinton and Johnson. A photograph of King being greeted by the late Supervisor Hahn is hung in two places there and in at least six others around the hospital.

Down winding hallways is one of the hospital's greatest points of pride — a trauma unit with state-of-the-art equipment. More gunshot wounds have been treated here in recent years than at any other hospital in the county. Many in surrounding neighborhoods credit the unit's surgeons with saving their lives or those of their sons and daughters.

"There's a lot of violence in the world today, especially in this community," said Lee Russell, 40, yanking up his shirt to display rope-like scars from a November 2003 shooting and stabbing. He praised the King/Drew doctors and nurses, saying that if the trauma center hadn't been nearby, "I would be dead…. I'm their walking miracle."

Last month, the Board of Supervisors voted to close the trauma unit to focus on fixing the rest of King/Drew, which like other county hospitals treats patients regardless of insurance status. In September, the board agreed to hire private turnaround consultants for $13.2 million. The supervisors' actions were their strongest to date, brought about only by threats to King/Drew's federal funding and national accreditation.

The trauma unit's closure, especially, drew residents' ire. "Don't disrespect or underestimate our community," read a banner hung last month at a rally of more than 1,000 hospital supporters.

King/Drew has become the "proxy for an entire community's identity," said Los Angeles civil rights attorney Connie Rice, who is African American.

That creates tension between those who see the hospital in strictly medical terms and those who see it as an embodiment of their dreams for racial self-determination.

"You're talking about the fact that the nurses weren't trained to use monitors," Rice said, "and they're going back to '60s Watts."

*

Community of griefOver the years, King/Drew has created another community, one bound by a common grief.

Jereatha Thomas belongs to it. She rushed her 27-year-old daughter, Demetria, to King/Drew in June 2003.

In the emergency room, printouts from three electrocardiograms stated plainly that Demetria Thomas had suffered a massive heart attack. Two labeled it "acute," the other "extensive."

No one acted on the findings for more than 10 hours, as doctors pursued other theories. By the time a cardiologist pointed out the obvious, it was too late, said two experts who reviewed her medical records for The Times.

Two days later, shortly after being transferred to Harbor- UCLA Medical Center for more specialized care, Demetria died.

Jereatha Thomas has never recovered. She moved out of the house she shared with Demetria, unable to live with the memories. She works three jobs until she's too tired to think.

"Since the time my daughter passed away, people have come up to me and said, 'My aunt, my uncle, my friend died the same way,' " Thomas said. "It was a lesson to be learned for me. I would never go back to King. Never, ever."

Thomas decided to hold the hospital accountable in the only way she knew how: She sued. Her case is pending.

Every hospital makes mistakes, some of them fatal. Filing a lawsuit is one of the few recourses patients and their families have when something goes wrong. But taken together, the malpractice cases involving King/Drew portray a place where things often go wrong — sometimes in the same way, over and over.

King/Drew spent $20.1 million on malpractice payouts during fiscal years 1999 to 2003, an extraordinary sum for a public hospital its size in California. Adjusting for the number of patients the hospital saw, that figure is more than at any of the state's other public hospitals or the University of California medical centers.

Even County-USC Medical Center, which is three times larger and not without troubles of its own, spent less. (King/Drew's payouts cannot be compared to those at public hospitals outside the state, because California has strict limits on malpractice damages.)

The Tasejos' award was added to the tab this October, more than four years after Dunia's death. Weary of the legal battle, the family settled for $195,000.

Her father plans to build an altar at her grave in Guatemala, enshrining the dress and shoes she wore that July day.

"I want to get the [legal] papers so I can put them in the tomb and say, 'Look. It's over, honey,' " he said.

Malpractice awards are just one sign of trouble at King/Drew.

From 1999 to March 2004, the hospital was cited for violating California health regulations more often than 97% of hospitals statewide, according to a Times analysis of state data. It had more violations than any of the county's three other general hospitals.

The two most prominent national accrediting groups rate King/Drew among the nation's most troubled institutions.

It is the only hospital in America to have received the lowest possible rating in its last two reviews from the Accreditation Council for Graduate Medical Education. The group has ordered the closure of three of King/ Drew's 18 doctor-training programs: surgery, radiology and neonatology. A fourth, orthopedic surgery, may be phased out under pressure from the council.

King/Drew is also one of only seven U.S. hospitals that the Joint Commission on Accreditation of Healthcare Organizations has said should lose overall accreditation this year. The group accredits 4,579 hospitals nationwide. King/Drew has appealed the decision, but if it fails, it could be forced to close all its doctor-training programs and lose nearly $15 million in private insurance contracts.

"This hospital," said Dr. Dennis O'Leary, the joint commission's president, "has problems of orders of magnitude that are substantially greater than almost all other hospitals in this country."

Even the top county health official finds King/Drew's failings hard to fathom.

"I'm not sure who would imagine the depths of the problems," said Dr. Thomas Garthwaite, director of the Department of Health Services. "I'm not sure anybody has the life experiences to prepare themselves for this."

It is only through brutal experience that some patients and their families learn of the dangers at King/Drew.

Sherry Ridley, a 43-year-old airport security guard, underwent elective surgery there for ovarian cysts in November 2002.

First a doctor in training stitched through her colon in error, essentially blocking it, according to a surgical note in Ridley's medical records. No one caught the mistake for two weeks as her stomach painfully bloated. A second resident's belated repair job failed.

Over the next couple of weeks, a senior surgeon opened the patient up eight times, trying to scrub out a worsening infection. More medical equipment sprouted from Ridley nearly every day; wires and hoses protruded from her like tentacles. Swollen with fluid, she ballooned from 187 to 321 pounds. Bands had to be looped around her abdomen to hold her incision together.

Ridley, the mother of two sons and one of seven close-knit siblings, died five days after Christmas.

"My sister went in there healthy," said Gail Gordon, her eldest sister. "She went from a human being to a monster when she passed."

The number of patients harmed or killed at King/Drew is impossible to tally.

The Times asked Michael Pine, a national health quality expert, to compare complications and deaths at King/Drew with those at all other hospitals in California. After reviewing six years of data collected from hospitals by state health authorities, Pine said he was unable to reach firm conclusions. King/Drew, he said, often left out information about whether patients came in with complications or developed them at the hospital.

"There are definite problems in the way they're reporting their data," said Pine, whose firm is based in Chicago.

Separately, The Times discovered cases in which medical errors were reported neither to the county coroner nor the state health department as required — let alone to uncomprehending families.

The circumstances of Barbara J. Robinson's death might never have been known but for a last-minute call to the coroner's office from a King/Drew surgeon who was not involved with her care.

In February 2002, doctors suspected that fluid was building up around Robinson's heart, dangerously compressing it. But when they finally sought an echocardiogram image to confirm their theory — 11 hours after her arrival at the King/Drew emergency room — the only technician available said he wasn't qualified to perform the procedure, according to Robinson's medical records. Three hours later, the patient began to slip away. Without an image of her heart for guidance, a doctor seeking to drain fluid plunged a needle into her chest.

Robinson, 46, died within hours. A doctor wrote on her preliminary death certificate that she had died from natural causes.

After her body had already been embalmed, the King/Drew surgeon called the coroner's office, suggesting that Robinson's doctor might have made a fatal mistake.

An autopsy confirmed that the needle had struck her coronary artery, spilling blood from her heart.

Cases like these sometimes pass unnoticed.

But many of King/Drew's mistakes are well known to the elected leaders responsible for overseeing the hospital, a board so powerful its members are called "the five little kings."

*

Vows of actionSpurred by media reports of lapses in patient care at King/Drew, county Supervisor Yvonne Brathwaite Burke held a news conference to announce "swift and decisive action."

"Due to a series of highly publicized problems, irregularities, illegalities and tragic mistakes … the public's confidence in this major county medical facility has been shaken," she said. "It is unacceptable for anyone who depends on King hospital … to fear that they won't get the level of care they expect and deserve."

It was time for "drastic action." The hospital, she said, needed a "crisis management task force" and a major administrative shakeup. Her colleagues on the board approved Burke's plan.

"This," said Supervisor Zev Yaroslavsky, "is a major step; it's a beginning at MLK."

Those remarks might have been made this year. In fact, they were delivered nearly nine years ago.

Many such pledges have been made in the years before and since. But they have not produced meaningful change.

In 1989, the supervisors were jolted by a Times investigation into King/Drew that described a series of botched cases. In one, an 18-year-old shooting victim survived even though her throat was mistakenly slit by trauma surgeons.

The supervisors ordered an investigation and pushed for a top-level task force. They also removed the hospital's administrator, provoking a wave of community protest.

King/Drew drifted out of the spotlight — for a while. But notorious cases arose periodically in subsequent years, grabbing public attention and prompting more promises of reform.

In 1992, Nelson Yamamoto, a 26-year-old sheriff's deputy, was taken to King/Drew with four gunshot wounds. Joking with nurses as he arrived, he was dead two days later. The coroner said the deputy died of the gunshot wounds. But the district attorney later faulted the care provided by doctors, in particular a surgeon who administered a lethal combination of heart drugs.

"We have no doubt that there are many competent, dedicated healthcare professionals at Martin Luther King hospital," the district attorney's report said. "But we cannot turn a blind eye to the facts as we have found them."

The doctors involved in Yamamoto's care were never charged. The incident, however, cemented some police officers' impressions that King/Drew was not a safe place to go.

In 1994, Aleta Clemons, a 42-year-old woman who went to King/Drew for a hysterectomy, was infused with blood that had tested positive for the AIDS virus. But no one had bothered to check the test results.

In 1998, Blanca Maldonado, 52, drank a glass of tissue preservative, a poisonous chemical mixture accidentally left on her hospital bed stand by a doctor in training. She staggered to the closest nursing station, pleaded for help and died a short time later.

Each of these cases led to promises by the Board of Supervisors that King/Drew would be fixed.

A pattern emerged: A crisis would bring superficial reform, followed by a short period of relative calm, soon to be followed by another crisis.

"Members of the Board of Supervisors tiptoe around Martin Luther King hospital," said political consultant Kerman Maddox, who is black. "They have to pay attention when they're forced to pay attention, but when they're not … they'd rather ignore it and hope it'll go away. They'd rather not get in battles with people in the community, because they would appear to be racially insensitive."

Few people have been in a better position to know what is going on at King/Drew than the supervisors. They receive county, state and federal reports spelling out the hospital's most severe patient care failings, along with other documentation.

The supervisors also must sign off on malpractice payments of more than $100,000 — two dozen from King/Drew in the last six years alone. Confidential paperwork describes precisely what went wrong and how the hospital plans to fix it.

Yet, again and again, the board has professed shock at the hospital's tragedies.

Last year, when a series of crises erupted at King/Drew, the supervisors — four of whom have been on the board more than a decade — reacted much as they had before. They called for another task force, which had virtually the same mission as the 1996 group and was even staffed with some of the same people.

Top health department officials took control of King/Drew's operations. And under their watch, the hospital was twice threatened with the immediate loss of federal funding for, among other things, repeatedly bungling medication orders.

When the supervisors announced plans early this year to scale back the hospital's prized neonatal unit, community activists, led by Rep. Maxine Waters (D-Los Angeles), geared for a fight.

Waters threatened at a protest meeting to climb "on top of [the] desk" of health department officials. A short time later, the county backed off, saying its proposal needed further study.

While the board vacillates, patients suffer.

*

A cry of despairIn July 1994, Dr. Wilbert Jordan drove to a gold-colored house, trimmed with white, just a block from King/Drew.

Jordan had the sort of news he felt he could deliver only in person: The hospital had given Aleta Clemons, a mother of three, HIV-tainted blood. She might be infected with the deadly virus.

She seemed almost calm when he told her. It wasn't until he was outside that he knew she understood.

"I will never forget the scream and the cry that she let out as I was walking to my car," the doctor said. "It was chilling."

Jordan, a specialist in infectious diseases, said hospital officials had tried to dissuade him from telling Clemons about the mistake. He felt it was his duty.

Two weeks later she learned that she was, in fact, infected with HIV.

Clemons, now 53, hadn't planned on going to King/Drew at all. She was supposed to have her hysterectomy at Harbor-UCLA. She'd even stored her own blood there in advance, on a doctor's advice. But when she began hemorrhaging unexpectedly, her sister took her to King/Drew because it was closer.

"I begged her not to take me there," Clemons said. "But she said that I would have bled to death."

In late 1995, Clemons took her questions and concerns about what happened to Supervisor Burke. Jordan went with her.

Burke was full of promises, Clemons recalled, wanting to make sure she had a job, a formal apology and a house of her own. Clemons said she never got those things.

Burke said she did not recall meeting with Clemons. "At no time did I say I would get her a house or a job," the supervisor said. "Whenever she calls, we try to do whatever we can to assist."

Clemons did get a $450,000 legal settlement, paid out over more than a decade, and the promise of free lifetime care — at King/Drew.

"This," Jordan observed, "is like having to live with the person that raped you."

Even 10 years later, Clemons thinks about going to the Board of Supervisors to remind it of Burke's other pledges.

"I tried to get up the courage, because I really want to talk to them face to face," Clemons said. "Every time, I just get depressed. I can't go."

In recent months, her health has deteriorated markedly. Her gait is no longer steady. She takes 16 pills daily.

She lives in King/Drew's shadow. She can see it from the rear window of her apartment.

"Every time I look at that hospital I think about what happened to me," Clemons said. "That hospital took my life away from me."


Times staff writer Steve Hymon, researcher Scott Wilson and data analyst Sandra Poindexter contributed to this report.

Copyright © 2014, The Baltimore Sun
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