Quadriplegic Veteran’s Death At San Diego VA Might Have Been Avoidable, Report Says
Speaker 1: 00:00 An investigation into a death at San Diego's VA hospital last year has found lapses in training and procedure. The VA's office of Inspector General issued a report on the death of a 68 year old quadriplegic veteran who died when his breathing and speaking devices malfunctioned. The inquiry found a tragic sequence of events led to the veterans being poorly monitored when his ventilator accidentally disconnected. Joining me is I knew source reporter Jill Castillano and Jill welcome. Thank you. The name of the veteran who died has not been released, but what did the report tell us about him? Right. His identity has been kept private for the sake of the family, but we do know like you said, he was 68 years old. He was Samoan and in the summer of 2017 he was in American Samoa trimming a tree when he fell and that resulted in paralysis in his arms and legs. Speaker 1: 00:54 Since then he's been developing a lot of health problems and he needs, he needed a ventilator to help him breathe and an eating tube to help him eat among other things to help him function on a regular basis. And was there any particular reason that he was at San Diego VA hospital this time around? Yes. So he had private care at a nursing home, but his situation was really complex and he developed pneumonia over and over again and he had a lung collapse and it resulted in him being transferred to the hospital for more intensive care. So at the time of his death he was staying in the spinal cord injury unit at the VA Hospital. When did things start to go wrong leading to his death? The morning of his death, a respiratory therapist entered his room and was using a PMV device on him. This is a special device for ventilator patients that can help them eat and speak. Speaker 1: 01:49 It redirects air flow from their ventilator and because of the way the device works, it creates this issue where the patient's alarm goes off unnecessarily. This is an emergency alarm that's supposed to go off when there is some kind of real problem with the ventilator, but it was going off when it didn't need to be. So the nurse turned down the volume on this alarm then left the room and throughout the next few hours nurses and staff members came in and out checking in on him one time. Shortly after noon they come in and they realize that his ventilator had disconnected and the alarm did not go off to alert anyone and he was unresponsive, unfortunately died shortly after that. And is that because they didn't really know how to correctly use the PMV device? They weren't trained to use the device, but also staff had told investigators when they came to interview them that it was actually standard for them to turn the volume down on the alarms when this device was being used. Speaker 1: 02:48 The problem with that of course is if there is a real problem with the ventilator, there's no one who's going to be notified. So the report concluded that that was not a proper thing to do and at the very least someone should have been with the patient if no one was going to be notified in case of an emergency. Do we know how the ventilator got disconnected? Unfortunately, because nobody was with the patient at the time of his death. We can't say for sure, but we do know it's possible that it spontaneously disconnected or if he moved and adjusted his position, it could have become disconnected either way because of how severe this patient's disability was. He would not have been able to reconnect it himself and he would have needed help from a nurse or a staff member at the hospital. Well, we're the inspector generals findings about this incident. Speaker 1: 03:38 You know, one of the most troubling things is that in the course of investigating, they found that people who have worked on the care team for this patient had experienced this before, that his ventilator has disconnected in the past, so they knew this was a problem and they never reported it through the patient safety reporting system, which was required by hospital policy. Then if you factor in that nobody was with him at the time and they turned his volume down on his alarm, you can see as the report concludes, that they created a real risk for this patient that they didn't mitigate. They didn't protect against this risk at all. And the report concludes that they may have contributed to his death what it's been, the response from the VA hospital about this death and its aftermath. So the response according to the report has been prompt and appropriate. They lauded the way that the staff handled it after the event occurred. Um, the staff decided to shut down any new spinal cord injury patients with ventilators from coming in to their unit to make sure that they could ensure the safety of all of those patients. They also trained new staff members. Um, they're, they train staff members and they started using new equipment so that way they could prevent these kinds of ventilator disconnects from happening in the future. Hopefully, I've been speaking with I new source reporter Jill cast. Alana, Jill. Thank you. Thank you. Speaker 2: 05:08 [inaudible].