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COLUMN ONE : Medicine's Fatal Code of Silence : Eight-year-old Richard Leonard was undergoing 'minor surgery' when he died at a Denver hospital. His anesthesiologist was known as a problem. But the peer review system kept his parents in the dark.

Medicine's Fatal Code of Silence. FIRST OF TWO PARTS.


On the first of two pages, which included everything up to 10:30 a.m., Verbrugge added a notation indicating he'd listened with a stethoscope after inserting the ET tube. On the second page, which was entirely blank, he wrote in levels of blood pressure, pulse, oxygen and carbon dioxide at five- to 15-minute intervals.

When he finished, he insisted that Nurse Garcia sign off on the first page, to verify it had been created during surgery. After some resistance, she initialed page one, but refused to sign page two.

Late that afternoon, two nurses drove Jay and China home. There, minutes later, the Leonards broke the news to their 10-year-old son, Ted, as he bounded up the front steps, fresh from his first Rockies baseball game.

Why did this happen? the Leonards cried to friends and relatives all through that long first evening of Richard's death. Shocked and disbelieving, they kept reliving the day, trying to change the ending.

Friends cried with them. Some blamed God, some senseless fate. Richard's friend Michael thought it all his fault, for he believed he'd caused Richard's ear problem. "I accidentally kicked his ear when we were climbing trees," he sobbed to his parents.

No, no, they explained to their son. Richard had suffered a rare reaction to the anesthesia, a 1-in-15,000 chance.

An enzyme reaction--that's what the Leonards repeatedly told friends and relatives in those early days. That was all they knew. That was all they'd been told at St. Joseph Hospital.

NEXT: The Leonards unearth the truth.


Editor's Note: About This Story

The accounts in this story of Richard Leonard's operation, and of various meetings, conversations and reflections surrounding it, are drawn from numerous sources. They include sworn testimony at Dr. Joseph Verbrugge's disciplinary proceeding, the initial decision of the presiding administrative law judge, the final decision of the Colorado Board of Medical Examiners, exhibits and documents included in the proceeding's public record, reports from Dr. Verbrugge's psychiatrists, the deposition of Dr. Patrick McCallion, confirmations from St. Joseph Hospital lawyers and administrators, and direct interviews with many of those involved.

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