Introductory Statement From Shirley Barker, RN, BSN:
As nurses, we’re expected to be an “advocate” for our patients. Unfortunately, we are often stifled from fulfilling that role. I retired in 2013. During my 30 years of nursing for Los Angeles County, I was aware of medical errors leading to harm and sometimes death for patients in the hospitals where I worked. Yet, hospital policy did not permit nurses to discuss errors with patients and families.
During the last few years of my employment, I was assigned to risk management. I found that, in my opinion, patients were not adequately protected. Too often, medical errors were covered up and lessons were not learned.
My father died as a result of medical errors. That hit me hard. I believe it is now an extension of my nursing career to openly discuss the issue of fatalities from undisclosed medical errors. It is all too common.
Q & A:
In the following Q & A, Nurse Barker recalls the circumstances surrounding the death of Deputy Sheriff Nelson Yamamoto, a patient she cared for in a Surgical ICU. Mr. Yamamoto was shot by a murder suspect in Los Angeles in 1992. Tragically, he died two days later in the ICU. The hospital’s Medical Director, Dr. James Haughton III, said: “Yamamoto had lost so much blood by the time he underwent surgery that, even with a transfusion of more than 25 pints, doctors could not revive him.” Not true, according to the Los Angeles District Attorney. The DA, after a lengthy investigation along with the Medical Board of California, determined that medication errors caused Nelson Yamamoto’s death. The Medical Director had participated in a cover-up of fatal med errors.
(The following interview with Nurse Barker was edited for clarity and brevity.)
Sheriff’s Deputy Shot By Murder Suspect
By Bob Aller: November 18, 2020
On Sunday evening, March 29, 1992, Los Angeles County Sheriff’s Deputy Nelson Yamamoto and two fellow officers responded to a complaint that someone had been threatened by a “man with a gun.” Upon arrival, one of the officers observed three men with handguns in a garage converted into living quarters. The deputy ordered the men out of the garage. Two men came out firing as they ran. The Deputies returned the fire. Officer Yamamoto was hit and suffered potentially fatal wounds from .357 shots in the abdomen and shoulder. The bullets that hit Officer Yamamoto came from the gun of a murder suspect.
The Officer was rushed by ambulance to a trauma center at the Martin Luther King Jr./Drew Medical Center. The facility was a Los Angeles County 233-bed teaching hospital located in the Watts area of Los Angeles.
That night Mr. Yamamoto received extensive trauma surgery. It was reported that “surgeons worked nearly eight hours in two consecutive operations to repair his colon and intestine, and to tie off blood vessels in his pelvic area and thigh.” After surgery, he was moved to the 12-patient Surgical ICU, an open area with curtains separating patients. Nurse Barker worked in the ICU.
Q. Could you describe Mr. Yamamoto’s condition?
A. Nurse Barker: I had been off work from Saturday through Monday. My week started on Tuesday at 7 am, with a 12-hour shift. Mr. Yamamoto was my only patient.
As a patient in critical condition, I paid close attention to the nuances of his condition. I remember reviewing his flow sheets from the Sunday night surgery. He had experienced both hemorrhagic and hypovolemic shock from the gunshots. Nelson had been on a ventilator with multiple drips for just over 40 hours. He was making good progress. Epinephrine (adrenaline) had kept his blood pressure in safe limits, around 140 over 80. Pretty decent for the circumstances. Having read the details from his surgery, I thought to myself, “this guy is superman!”
Even though Mr. Yamamoto suffered severe shock, he never lost perfusion to the brain. His pupils were not fixed or dilated. He was responding with a gag, with blinking, with squeezing people’s hands. In short, he was recovering. His response to stimuli and commands was evidence of his progress. The way he responded to visitors was another strong signal he was getting better.
Mr. Yamamoto’s parents and fiance regularly came into the room to see him during the course of the day. They shared their concerns with me.
Fellow officers also came to see Officer Yamamoto. During their visits, he would squeeze their hands. I slowed down the visits to give him some rest. His eyes were not fixed and dilated. He had a gag reflex. I would say to him, Mr. Yamamoto, “Can you hear me?” Though he couldn’t speak since he was on a ventilator, he would squeeze my hand and nod his head affirmatively.
Q. What happened when the Chief General Surgery Resident arrived?
A. Nurse Barker: Around 5 pm, Jonathan Heard, the Chief General Surgery Resident, arrived at Mr. Yamamoto’s bedside with a first-year resident, Charles Jones. They both were in the surgery with Mr. Yamamoto on Sunday night. We discussed the flow sheet, the trends in vital signs, the labs, the blood gasses, the urinary output. Though Mr. Yamamoto was still in critical condition, I explained how he was clearly trending in the right direction.
Q: Did Dr. Heard alter Mr. Yamamoto’s medication regimen?
A. Nurse Barker: After I described the patient’s status, Dr. Heard said he wanted to lower Nelson’s heart rate. He said he was going to administer the medication verapamil. As I recall, Nelson’s heart rate was around 110. Since tachycardia starts at 100, 110 was only minimally high. Based on Nelson’s condition, I thought Dr. Heard’s plan to administer verapamil was not a good idea. Nelson’s current medication, epinephrine, was working well and his overall condition was improving.
Q. Did you or anyone object to Dr. Heard’s plan?
A. Nurse Barker: Dr. Jones, the first-year resident also standing at the bedside, said to Dr. Heard: “I believe titrating down the epinephrine drip would be best.” I agreed with Dr. Jones. However, Dr. Heard resented Dr. Jones’s suggestion. I recall he said: “Shut up, if you know so much, I wouldn’t be here.” I believe Dr. Heard was inferring he was smarter than Dr. Jones. That was a tense moment.
I recall that Dr. Heard then sat down at the desk. He made a short phone call. Our ICU was an open and noisy area with monitors beeping, phones ringing, and staff talking. I could hear the sound of Dr. Heard’s voice but I didn’t hear what he said. The conversation was brief. I don’t know if he consulted with his attending or anyone else.
Right after the phone call, Dr. Heard then went ahead and pushed in the verapamil with an IV. I started documenting vital signs to have a baseline for Nelson’s response to the verapamil. However, there was little or no response at the time.
As a resident, Dr. Heard often consulted with the Director of our ICU, Dr. Meade. I found it odd that in this high-profile case he didn’t consult with Dr. Meade, who was present in the ICU. As the minutes passed while we monitored Nelson, Dr. Meade walked by with some residents. He said: “Hey Shirley, how are things going?” I said verapamil was just administered. I remember he raised an eyebrow a bit, quizzically, but proceeded on his rounds.
We waited maybe a total of about 15 minutes without a change in heart rate.
Q. What was Dr. Heard’s response to no change in the patient’s condition?
A. Nurse Barker: Next, I remember Dr. Heard saying that he wanted me to administer an additional medication, labetalol. I thought labetalol was too risky. He gave me a look that said you’re going to administer labetalol, aren’t you? I said: “I’m not going to do it.” This was the first time in my nursing career I refused to administer medication. Dr. Heard, without any further discussion, walked out to the medicine cabinet and returned with the medication and syringe. He took the IV tubing and pushed in labetalol. (In our hospital it was common for physicians to administer medication. In addition, oversight by the pharmacy was not what it is today.)
Interactions of Verapamil, Labetalol, and Epinephrine
Hospital Watchdog asked a Clinical Pharmacist, Dr. Arthur Wernick, Pharm.D., CMTM, in Tampa/St Petersburg, Florida, to review and comment on mixing these three medications.
“Although the physician did not observe a lowering of the heart rate from verapamil, the drug was still circulating and possibly biologically active. Adding labetalol to verapamil can result in a slowed heart rate and severely low blood pressure. The combination of these two drugs can also stop the heart from beating. In addition, labetalol combined with epinephrine can also trigger a significant slowing of the heart rate. These three drugs interacting could have stopped the heart from beating.”
Q. What was Mr. Yamamoto’s reaction to the Labetalol?
A. Nurse Barker: Very soon Mr. Yamamoto’s blood pressure and heart rate began to decline. It was rapid. I saw the panic on Dr. Heard’s face! He tried to reverse Mr. Yamamoto’s reaction by administering additional IV fluids! Sadly, the vital signs continued to drop. Over several minutes, Mr. Yamamoto’s blood pressure and pulse rate fell precipitously. It was frightening.
Suddenly, the alarm system went off. It was loud. Dr. Heard tried to turn it off. He couldn’t. It was stuck. Dr. Heard moved quickly to initiate CPR.
As I rushed to get the crash cart I saw Dr. Meade, making rounds. I told him labetalol was used. He said: “Oh, no!” He rushed over to the bed. Dr. Heard, Dr. Meade, and others tried everything to save Mr. Yamamoto’s life. Their efforts went well beyond the normal time allowed for reviving a patient. Mr. Yamamoto could not be revived.
In the commotion, after the staff stopped trying to revive Mr. Yamamoto, I remember Dr. Meade sort of muttering, saying something like they didn’t want me in on his care! I could tell he was upset. At that moment I had no idea of the implications of what he said.
Q. What happened to Mr. Yamamoto’s chart?
A. Nurse Barker: After Mr. Yamamoto was declared dead I went to enter that information in the chart. But the chart was gone. I couldn’t find it anywhere. I paged Dr. Heard and asked: “Where’s the chart?”. “Oh,” he said. “I have it. I’ll bring it back.”
Taking the chart out of the room was concerning to me. We never let a chart leave the patient. Dr. Heard could have left the ICU and drafted a note and come back to make an entry. He didn’t do that. He took the whole chart. He might have consulted with others about the chart. I don’t know what transpired.
I documented my notes on separate paperwork. Things were chaotic after Mr. Yamamoto died. The chart would normally have been sent to the morgue. I never had an opportunity to read what Dr. Heard or other staff documented in the chart after Nelson’s death.
Q: What was Mr. Yamamoto’s family told?
A: Nurse Barker: When Dr. Heard returned to the ICU he said to me, “Do you want to go with me to tell the family?” Though I was overwhelmed, I went with him.
In the hallway just outside the ICU, Dr. Heard informed the family that Nelson’s complications were so severe that he couldn’t make it. He told them we tried to revive him but he just didn’t make it. Mrs. Yamamoto was crying. Her husband was holding her up. His girlfriend was screaming and crying. I tried to console her. Other sheriff’s deputies standing nearby could sense what happened. I was shaken and upset. In a state of speechlessness, I went back to the ICU. For me, personally, the tragedy was devastating.
Q: Did you report the incident to an administrator?
A: Nurse Barker: I reported what happened to my Nurse Manager, Barbara Bundage. She was not present in the ICU when it happened. When she came over to me and asked what happened I told her exactly what happened.
Autopsy Report Provided False Information
The Autopsy Report from Deputy Medical Examiner Carpenter stated the immediate cause of death was “multiple gunshot wounds.”
However, in the same Autopsy Report the pathologist who inspected the multiple gunshot surgical sites reported no leaks, bleeding, or other complications at the multiple surgical sites. According to a physician reviewer consulted by Hospital Watchdog, the Autopsy Report did not provide any evidence that the immediate cause of death was multiple gunshot wounds.
In addition, the Toxicology Report did not list, as required, the medications taken by the patient, including verapamil and labetalol. This omission, appearing as a cover-up of fatal med errors, also suggests King/Drew hospital may have withheld from the Medical Examiner chart notes and medical records created shortly before the time of death.
The Medical Examiner’s claim that the immediate cause of death was “multiple gunshot wounds” appears to be false information. That claim, however, is consistent with the hospital Medical Director’s false statement that the patient could not be revived from his wounds.
Clearly, the patient was recovering from the surgical repair of his wounds prior to the administration of verapamil and labetalol.
A Hero’s Funeral
An estimated 4,000 uniformed officers from throughout Southern California attended Mr. Yamamoto’s funeral. They believed Nelson died from his gunshot wounds.
Nelson Yamamoto had been with the Sheriff’s Department for three years. He had been in the field for just two months. He held a degree in criminal justice and was a fitness devotee. He was engaged to be married to schoolteacher Michelle Tomi.
Days after Mr. Yamamoto’s death, a credible complaint was filed with a County agency. The complaint alleged Mr. Yamamoto did not die from gunshot wounds. What followed was an investigation that lasted three years. Three government agencies participated: the Los Angeles County District Attorney, the Medical Board of California, and the Los Angeles Sheriff’s Homicide Division.
Early in the investigation, doctors’ attorneys strongly objected to “alleged” aggressive DA interviews without a lawyer present. To override the physicians’ resistance to interviews, the DA empaneled a Criminal Grand Jury.
The doctors and nurses involved in Mr. Yamamoto’s care, including Dr. Heard, Dr. Jones, and Nurse Shirley Barker, were subpoenaed to testify.
Q. Did anyone try to influence your grand jury testimony?
A. Nurse Barker: Yes. Shortly before my scheduled testimony, I was called into a meeting with hospital administrators who were physicians. One of them was a surgeon with whom I had worked in an OR. I found they were leaning towards omitting the fact that Labetalol was administered! When I insisted the drug was administered by Dr. Heard, they insisted it’s possible Dr. Jones administered it since he was a first-year resident! I was adamant. I said Dr. Jones opposed using labetalol. It appeared that the administrators were trying to make Dr. Jones the “fall guy.” My recollection of events did not sit well.
I was asked: “You’ve worked here for many years. Why wouldn’t you administer the labetalol?” I said, “It wasn’t appropriate considering the meds Nelson was already taking.” They asked, “Have you administered labetalol in the past in the ICU?” I said, “Yes I have, but it was under different circumstances. In this case, labetalol wasn’t appropriate.”
The administrators left the room for a few minutes. When they came back, I was told an attorney would attend the grand jury session and advise me on my testimony.
Q. Did an attorney advise you on what to say to the Grand Jury?
A. Nurse Barker: An attorney tried. I was standing outside the Grand Jury courtroom, waiting to be called. A man came up to me and said, “Are you, Shirley Barker?” I responded, “Yes.” He said he was an attorney for the County. I was expecting this encounter. He said, “I’d like to discuss what you’re going to say in your testimony.” I had thought about my response if anyone tried to sway my testimony. I was prepared: “I don’t want to discuss the case. I’m sticking with what I know. I don’t wanna talk to you!” The lawyer could tell I meant it. He walked away.
Soon I went into the courtroom and testified before the Grand Jury. I told them exactly what I had observed. I told them I believed the use of labetalol caused Nelson’s death.
A few weeks later, Dr. Jones, the first-year resident, approached me in the ICU. He gave me a hug, thanking me for telling the truth. Since Dr. Jones had also testified before the Grand Jury, I assumed he learned he had been targeted as the “fall guy.” Fortunately, that didn’t happen.
Hospital Vice-Chair Of Surgery Refuses To Testify
According to the district attorney’s report, Dr. Rosalyn Sterling-Scott, the hospital’s Vice-Chair of Surgery, had been asked by her boss to act as the supervising physician for Nelson Yamamoto, removing other doctors from the case. Dr. Sterling-Scott, however, had a different take on the events. She said she only offered to “cover” for a tired surgical resident so he could get some sleep. However, when called to testify, Dr. Sterling-Scott refused to testify. She took the 5th.
District Attorney Report Issued in 1995
Finally, in July 1995, the Los Angeles District Attorney issued a 160-page report, concluding that Dr. Heard had administered a lethal combination of cardiac drugs to Mr. Yamamoto.
In addition, the report revealed that “progress notes” were missing from Nelson Yamamoto’s chart.
According to the LA Times, the LA District Attorney concluded there was sufficient evidence for charging Dr. Heard with involuntary manslaughter. However, the DA chose not to file an action. He thought it was unlikely a jury would convict the physician.
LA County Settled Lawsuit With Mr. Yamamoto’s Father
The County settled a lawsuit for negligent care filed by Mr. Yamamoto’s father, Henry.
In honor of Nelson Yamamoto, a street in the Lynwood area of Los Angeles was renamed “Deputy Yamamoto Place.”
Recalling Events From The Past
Nurse Barker made a painstaking effort to recall events from nearly 30 years ago. She indicates that while some details may be out of sequence or slightly altered in her memory, the key events are accurately described.
Do You Have An Experience Like Nurse Barker’s?
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