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The stunning truth of a sister's death

A family's special bond with Brotman Medical Center is shattered when it learns details of what went wrong.

September 09, 2007|Tracy Weber | Times Staff Writer

Finally, the inspectors said, as Brown's condition worsened on the night of July 4, no doctors examined her.

Even as her vital signs plummeted in her final three hours, there was no evidence that her nurse alerted her superior or any physician, according to the report.

The nursing staff was cited for its repeated failure "to act as the patient's advocate."

A sense of betrayal

After they learned what happened, the sisters -- driven by anger and a sense of betrayal -- sought to hold the hospital and its caregivers accountable.

They sent portions of the inspection report in January to the Medical Board of California, which oversees the conduct of physicians, and to the state Board of Registered Nursing. Then they waited.

As the months passed, Diamond and Allen grew bitter.

Diamond angrily called the medical board, accusing officials of dragging their feet.

Allen sent pleading letters to everyone she could think of: local, state and federal lawmakers, the mayor, reporters.

"It's like bumping your head up against a brick wall," Allen said.

In April, Brown's family sued the hospital, the doctors and other hospital staff for more than $30 million, alleging battery and abuse of a dependent adult. The suit is pending. Salceda denied the allegations. Houston, Torres-Garcia and Brotman filed motions to dismiss the suit, contesting the legal basis for the complaint.

As time passed, Allen kept replaying Brown's final days in her head, searching for a moment she could have done something different.

Should she have pressed harder?

Knee surgery kept her out of work after Brown's death, but later, after all that had happened, she couldn't go back. She quit.

Most days she visits the vault where her sister's ashes lie to play the oldies she loved. "She can hear it," Allen said. "I know she can."

Review promised

In June, more than 11 months after Brown's death, Brotman promised the state that it would review or revamp almost every process and procedure identified by inspectors in the case, including such basics as when nurses should alert their bosses or doctors to a patient's deteriorating condition.

After refusing for weeks to answer a Times reporter's questions about the case, Brotman officials said in a long interview that the failures in Brown's case were not as clear-cut as the state report portrayed.

Inspectors didn't review outpatient records that might have provided justification for Brown's emergency hysterectomy, including a prior history of vaginal bleeding and fibroids, the officials said. Nor did they consider nursing notes and other evidence suggesting that Brown's final nurse did much more to aid her than was documented in the medical record.

As for the sisters' complaints that the hospital shut them out, Brotman leaders said it was Brown's primary doctor's responsibility -- not theirs -- to explain what happened.

"The hospital," Levine said, "does not have a lead person who is supposed to take care of this unfortunate job."

In July, the sisters got a final shock: A three-page letter from the state medical board arrived, explaining that its investigation of Brotman physicians was closed. Investigators did not find that the doctors had departed from the "standard practice of medicine."

Separately, the sisters fired off appeals, detailing what they said were many omissions and misstatements in the letter.

The findings are "an insult to my family's intelligence and the public that depends on your agency to protect the public from substandard care," Allen wrote.

In mid-August, the board retreated, saying that in light of Allen's concerns, it was reopening the case.

Today, more than a year after Brown's death, the two feel they have been robbed of more than a sister.

Diamond has lost trust that the medical system -- and her fellow nurses -- put patients first.

Her anger flares when she sees a colleague ignore a patient's call light. "When the light goes on," she says, "you go see what the patient wants."

Allen has lost her passion for medicine altogether.

"I loved being a nurse," she said. "I just don't want to be a nurse anymore."

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