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DVT: Failure To Diagnose, Death for Navy Veteran

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Deep Vein Thrombosis (DVT) 

By Bob Aller: July 27, 2021

Deep vein thrombosis (DVT) is a potentially fatal blood clot that forms in the deep veins of the legs. A DVT may break off and make its way to a lung, blocking blood flow. Unfortunately, such a clot often becomes a fatal pulmonary embolism (PE). The CDC estimates that roughly 900,000 Americans have a DVT each year while 60,000 to 100,000 die each year as a result of a DVT.

The Centers for Medicare and Medicaid Services (CMS) requires hospitals to maintain policies that prevent such fatalities. However, in some cases, staff fail to comply. As a result, people die. DVT remains a leading cause of preventable hospital deaths in the U.S. and worldwide.

HCA Healthcare Hospital

The 436-bed Brandon Regional Hospital in the Tampa metro area is owned by HCA Healthcare. On December 1st and 2nd, 2020, an investigation was conducted at Brandon by the Florida Agency for Healthcare Administration. Investigators found that 62-year-old Keith Davis died in this hospital after staff completely disregarded the DVT risk assessment policy designed to prevent harm from a DVT.

Statement of Deficiencies Issued 

A Statement of Deficiencies was issued on December 17, 2020, by the Florida agency. According to the report, a “DVT Risk Assessment” was required at admission, at each shift, and at any change in the level of care.

The policy required early prophylaxis medication for the prevention of complications. The attending was required to write an order for prophylaxis at admission or, alternatively, to document why the patient did not need DVT prophylaxis. Yet, for six days in the hospital, despite medical records citing the history of DVT and the patient’s use of an anticoagulant, there was no documentation to indicate any compliance whatsoever with the hospital’s “DVT Risk Assessment” policy.

(Hospital Watchdog asked Brandon Regional Hospital to provide a copy of the “DVT Risk Assessment” policy, but Brandon did not respond to the request.)

Death Certificate Listed DVT As Cause of Death

The Florida agency reported that Mr. Davis’ death certificate, (certified by an independent forensic pathologist not associated with the hospital), stated the cause of death was pulmonary thromboembolism (PE) and deep vein thrombosis of the lower left extremity.

Presenting Symptoms

In addition to the patient’s medical history of a DVT, presenting symptoms included an extremely painful swollen left leg. The patient was unable to walk. The left leg skin was discolored, with irregularities and redness as seen in a cell phone image taken by Mr. Davis on October 1st. 

An examination of the medical records reveals that the ER-resident, the ER attending, and the medical unit attending each failed to assess whether Mr. Davis’ presenting symptoms and medical history reflected a possible DVT. An ultrasound and a D-dimer blood test are two key diagnostic tests for a DVT, according to the CDC and major healthcare providers. Neither was conducted.

Interview With Sabrina Davis, CMA

Hospital Watchdog interviewed Mr. Davis’ daughter, Sabrina Davis, CMA. (The interview was edited for brevity.) Ms. Davis was present with her father in the ER. In addition, Ms. Davis spoke with and texted her father during the following 5-days of hospitalization. Ms. Davis recounted that both she and her father made multiple oral pleas for an ultrasound to determine if a DVT was present. These oral requests described by Ms. Davis do not appear in the medical records.

Patient Requested An Anticoagulant

However, on October 12, 2020 (3rd day of hospitalization), Mr. Davis texted his daughter informing her that he asked the staff that day for an anticoagulant. No anticoagulant was provided.

Sequential Compression Device (SCD) Contraindicated

However, after informing staff that he used compression socks at home the staff promptly placed a sequential compression device (SCD) on his left leg. However, the use of an SCD prior to testing for a DVT is contraindicated by some experts.  We recommend screening patients by compression ultrasound routinely to identify significant occult DVT (unrecognized thrombus) capable of producing a pulmonary embolism before the placement of SCD’s since clinical examination is not reliable. 

“Doesn’t seem to care if I sit here and have a clot”

Mr. Davis texted his daughter again on October 12th expressing grave concerns. He said, “A second opinion is what I need. If I need some kind of surgery or something I will get it done… He (Dr. Moorthy, medical unit attending) doesn’t seem to care if I sit here and have a clot.” 

Q: What do you remember about that day when your Dad described the severe pain he was experiencing in his left leg?

A: It was Saturday, October 10, 2020. I texted my Dad at 9:31 am. Retired from the Navy submarine service, he lived near Tampa, in the small town of Thonotosassa. My text said, “Good Morning.” He texted back, “I need to go to the ER.” I phoned him immediately to find out what was going on. He said he had a painful, swollen left leg. His left knee was locked. He was unable to walk. I could sense severe pain in his voice. Instantly, I knew it was serious. I lived in Gainsville, two hours away. I told him I would call an ambulance and meet him at the ER. I called for an ambulance right away. Since my dad was immobilized and couldn’t make it to his front door, he called a neighbor, asking him to break down the front door so the EMTs could get in. I got my 7-year-old son situated with his dad before heading out. I was on the road when an EMT called to tell me what was going on. He said Dad was in an awful lot of pain. They were taking him to Brandon Regional Hospital, 10 miles from where he lived. The crises instantly brought back memories of a prior hospitalization with a DVT back in 2008. 

Sabrina Davis, CMS
Sabrina Davis, CMA Source: Instagram

Q: What were your Dad’s symptoms when he was diagnosed with a DVT in 2008?

A: Dad had extreme pain, swelling, trouble walking, and cramping. My Dad was taken to the same hospital, Brandon Regional Hospital, but it was 12 years earlier. At that time the ER doc promptly ordered an ultrasound. Dad had a large blood clot. The staff discussed putting in a filter in his vena cava to prevent the clot from advancing. He was promptly started on blood-thinning medication and the issue resolved over a period of days without the filter. He and I knew he survived a close call. Later, when I was in school studying to be a CMA, I learned more about the dangerousness of DVTs.  

Q: After the blood clot in 2008 how did your Dad manage his condition?

Keith Davis During Navy Service, Source: Courtesy of Sabrina Davis

 

Dad knew if this happened again it could be fatal. He had retired from the Navy. During his career, he served on a ballistic missile submarine, the USS Stonewall Jackson. He served as a Quartermaster involved in ship navigation. He knew how to follow a strict regimen. After that incident, he was diligent with taking his blood thinner. On any long car drive, he took breaks to stretch his legs. He had a daily walking regimen. I was thinking about that as I was driving to the ER. After my Dad’s death, I was unable to find a prescription bottle with his anticoagulant, Eliquis. He did have free samples of Eliquis. It made me wonder whether he had been taking Eliquis regularly before the DVT occurred.

Q: What happened when you got to the ER?

A: With the ER delays, I made it in time to be present during my Dad’s initial exam with what we thought was a regular ER physician. Later, I learned that Ali Kamel Al-Marzoog was a resident with a training license.    

My Dad and I told him that in 2008 my Dad was diagnosed with a large blood clot in his right leg. We explained that since that time my Dad had taken a blood thinner.

ER resident
Resident Ali Kamel Al-Marzoog

The resident ordered an x-ray and a CT scan. He came back with the result of the CT scan. He told us it showed fluid on the knee. I asked whether a CT scan could show if a blood clot was also present. He answered: “No.” I then requested an ultrasound to see if a blood clot was present. He said the test was not needed. He said the problem is fluid on the knee. I remember looking the resident right in his eyes. I touched my Dad’s knee that was warm to the touch. It was also swollen, bruised, and painful. I said, “These are symptoms of a blood clot.” I repeated my request for an ultrasound. Before I could finish my Dad spoke up and said that his left leg felt exactly as his right leg did in 2008 when he was diagnosed with a blood clot. Again, the resident insisted that an ultrasound test was not needed. He touched my Dad’s leg and acknowledged that my Dad’s leg was warm to the touch. The resident discarded my Dad’s medical history and symptoms. He repeatedly said the problem was fluid on the knee.

Q:  Were there any chart notes describing the supervision of the resident?

Sergio Martinez
Sergio Martinez, Attending ER physician Source: Facebook

A:  Dr. Sergio Martinez was the ER attending. He made only one entry that day in my father’s chart. He wrote: “I have reviewed and agree with the resident’s note and I have reviewed all labs, ECGs, and imaging studies or reports. I agree with the resident’s findings, exam, and plan.” Dr. Martinez spent a couple of minutes with us at the end of the ER consult. At that time we had no idea he was the attending who was supervising a resident. Though he claimed he reviewed all labs, there were no labs. Blood was not drawn in the ER. 

Note: According to the Statement of Deficiencies, Dr. Martinez, was required to write an order for prophylaxis at admission or to document why the patient did not need DVT prophylaxis. Dr. Martinez failed to make the required entry in the chart.

While Sabrina Davis was permitted to be with her Dad during the ER visit, once her Dad was admitted to the medical unit on October 10, 2020, the hospital’s Covid policy did not allow her to be present in his room. After the ER visit, all of Sabrina’s subsequent discussions with her father and hospital staff were by phone and text.

Q: How often did you talk to your Dad during the five days he was in the Medical Unit?

A: We talked to each other on the phone every day. My Dad didn’t understand why he wasn’t making progress.  He told me he wished they would finally check for a blood clot. He seemed frustrated with the care. He sent pics of his bad leg. He asked about his cat, July, who was staying with me at the time. Dad had a hobby rebuilding classic cars. While in the hospital he responded to many texts and emails from his wide circle of hobbyists.

Q:  Among your Dad’s texts, did any text indicate staff tested for a DVT?

On Monday, October 12, Dad texted me. He said, “the physical therapy lady pushed a folded sheet under my leg pointing the toes straight up. I yelped in agony. It hurt bad.” I read about the Homan’s sign test and wondered whether that’s what this was.

Hospital Watchdog consulted a surgeon knowledgeable about DVTs. He commented on Mr. Davis’ text: “From my training and experience, this is basically a Homan’s sign test and it was exquisitely positive. The resulting pain from this maneuver should have suggested to the physical therapist a possible DVT and provoked further testing to see whether a DVT was present or not.”

Nevertheless, the medical records do not include any entry by a physical therapist regarding the test described by Mr. Davis.
Q: Could you recall your Dad’s day of discharge?
Dr. Rathinam Moorthy
Dr. Rathinam Moorthy, Source: Medscape

A:  At 8:39 am on Thursday, October 15, I was talking to my Dad on the speaker function of the phone. I heard Dr. Moorthy (the attending who was also my Dad’s primary care physician) come into the room and tell my Dad “You’re being discharged.” I said, “Hi, Dr. Moorthy,” he was in and out of the room quickly. My Dad and I continued talking. We were having a good conversation. Later, at 10:09 am, we were texting. He was happy to get out. He did say he was still in pain and he wondered why his knee was still feeling just like it did when he went to the ER. But after 6 days of bed rest, he was ready to leave. He still could not walk or stand on his own. He was being discharged to a skilled nursing facility.

Q: Could you describe the call you received from the hospital that morning?
A: At 10:40 am, 30 minutes after I got off the phone with my Dad, I received a call from a number I did not recognize. I took my phone to my room because my son was on the computer doing schooling on zoom with his second-grade class. A lady asked if I was Sabrina. I replied, “Yes.” The lady bluntly informed me that my Dad had gone code blue. She stated he was not breathing and had no pulse. She asked, “What would you like us to do?” Those were her exact words.
I told her there’s no way. I had just spoken to my Dad and he was fine. He’s being discharged.
She repeated: “M’am, what would you like us to do?” I told her “You get my Dad back and you do not stop until you do.” She said OK. I could hear beeping and a lot of commotion. I asked when did this happen  She said about 10 minutes ago. I wanted to stay on the phone with her but she said she couldn’t. She needed to get back in the room. We hung up. I called back a few minutes later. She said they were trying but they hadn’t made any progress. I assured her my Dad was fine as I had just talked to him a bit ago. She told me not to get my hopes up. She told me: “Be prepared.” I asked if she could put the phone to my Dad’s ear. She said, “No, I’m not in the room.” I asked, “Can you go into the room?” She was insistent and said “No.” She said, “He wouldn’t hear me anyway.” That hurt. We hung up.
I called her back several times afterward. She did not answer. I never heard from her again.
Q: What happened next?
Blake Spain, MD Source: Facebook
Blake Spain, MD Source: Facebook

A:  I waited anxiously, not knowing what to do. Later, I would read in the medical records that CPR was conducted for 53 minutes. At 11:20 am, I got a call from a different number. It was Dr. Blake Spain. He was the Medical Director of the ICU. He called with a calming voice telling me that all life-saving techniques were unsuccessful. I asked him why did this happen? What time did this happen? He told me at 10:28 am a hospital physical therapist was in the room. My Dad tried to stand. He complained of dizziness. He laid back down in the bed and became unresponsive. That’s when code blue was called, he said. I asked Dr. Spain to put the phone to my Dad’s ear. He said he would do that. I made some promises to my Dad. I said, “I will find out what happened and if it was preventable.” I said, “I’ll make sure July (Mr. Davis’ cat), is safe and taken care of.” I cried harder than I ever have in my life.

Days later I was googling and came across a study that says a person’s hearing may be the last sense to go after death. I do feel like my Dad heard me. 

Q:  What made you think an autopsy was necessary?

A:   My Dad went in for knee pain and didn’t make it out alive. How does that happen? He followed the hospital’s treatment plan for six days. His doctor issued a discharge order because he was supposedly doing well. I was on the phone with Dad minutes before the code blue. He said he was fine. He was looking forward to being discharged. He wasn’t having heart problems. He had the same symptoms he had in 2008 when he had a blood clot. They had refused to conduct an ultrasound even though my Dad and I had asked for an ultrasound multiple times. I knew an ultrasound was the standard of care for a suspected DVT blood clot. I strongly suspected a blood clot killed my Dad. I thought an autopsy would answer that question.

Q: Could you describe the conversation with your Dad’s attending and primary care provider after you learned your Dad died?

A: Right after I spoke with Dr. Spain, I phoned my Dad’s physician, Dr. Moorthy. I was distraught. In fact, I was crying. I asked him to order an autopsy. He told me that he had never ordered an autopsy. I reminded him that earlier in the day when he told my Dad he was discharged I was on the phone with my Dad. He was doing well. I said, “An autopsy is needed.” I literally begged him to order an autopsy. Whatever I said had no effect. Dr. Moorthy refused to request an autopsy.

At that moment I sensed I wasn’t going to get any help. I told Dr. Moorthy I would get a private autopsy. I told him I would try to find out exactly what happened to my Dad. I was angry. I hung up the phone.

By refusing to order an autopsy, Dr. Moorthy avoided the possibility of having to address the reporting requirements of the Florida statute for an adverse incident involving a death.

Q: What did you know about ordering a private autopsy?

Forensic pathologist performed autopsy
Dr. Daniel Schultz

A:  From watching the news I knew next of kin could seek an autopsy. But I didn’t know anything about the process. I made a cold call to a medical examiner. As luck would have it he was compassionate. He explained the process and told me what to do. That same day, I hired a private forensic pathologist, Dr. Daniel Schultz, in Tampa, to conduct an autopsy.

Q: What were the results of the autopsy?
A: The results of the autopsy confirmed my instincts. Dr. Schultz reported that “the autopsy disclosed a massive pulmonary saddle embolism at the main pulmonary artery at the bifurcation of the right and left arteries.”
pulmonary saddle embolism
pulmonary saddle embolism: Source: healthline

“The use of anticoagulation therapy and a variety of measures… may have altered the course”

The autopsy reported the CAUSE OF DEATH as follows: Pulmonary thromboembolism due to deep vein thrombosis of left lower extremity. The pathologist also indicated… “The use of anticoagulation therapy and a variety of measures… may have altered this course.”
Q: How would you sum things up?
Luke & Keith Davis

The providers’ failure to follow the hospital DVT protocol led to my father’s death. To them, they lost nothing. No one from the hospital even called me to just say they were sorry.

I lost my best friend. Dad was always honest with me. He was always there to listen to me no matter what time it was. I loved listening to him play on his acoustic guitar. He always made sure I knew how proud he was of me. My Dad was always into sports. He particularly enjoyed watching his grandson progress with the game of golf. Luke started playing at age 4 and at age 7 Dad was cheering him on in tournaments. He told me “that boy is going places.” I know he is smiling upon us.

It’s quite common for patients who had a negative experience in a hospital to post their strongly-felt views on social media such as Yelp and Google. When Ms. Davis expressed her critical comments on the Brandon Facebook page in early January 2021, she included a link to the adverse ruling by the Florida Agency for Healthcare Administration.
On January 15, 2021, attorney Tracy Falkowitz wrote to Ms. Davis: “Brandon Regional Hospital insists that you cease and desist all such activities to defame the hospital and tortiously interfere with business practices. Should you have any questions regarding liability for any future postings or defamatory comments regarding Brandon Regional Hospital, I urge you to retain your own personal counsel.” 
Attorney Tracy Falkowitz, Source: lawyers.com

Ms. Falkowitz followed up with another letter dated February 23, 2021. “Further, it is my understanding that despite my prior notice, you have continued to post inflammatory and defamatory statements in social media. Please know that this is the final notice to cease and desist this activity. Should you continue to do so, my client will consider action against you for same.”

After Keith Davis died, Brandon Hospital management did not offer any condolences to Mr. Davis’ family. However, it seems management did feel a need to attempt to silence Sabrina Davis.

Florida is the only state in the U.S. with a law denying family members, other than a spouse or child under age 25, the right to seek accountability in the courts for grossly negligent care in hospitals. (FS 768.21 subsection 8)

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Robert Oshel

Autopsies should be a legal requirement for all deaths which occur shortly after discharge from hospitals. This is especially needed in Florida. The Florida law denying family members, other than a spouse or child under age 25, the right to seek accountability in the courts for grossly negligent care in hospitals is commonly referred to as the “free kill” law. That’s what it is; it allows “free kills.”. By preventing accountability, it incentivizes letting patients die rather than saving them after negligent care has been provided by physicians and hospitals. If the patient survives, he or she can seek compensation… Read more »

Suzan Shinazy

The patients family had to spend thousands to have a private autopsy done. How many people can afford to do that? How many medical errors are not recognized because of that?

Sabrina

I learned that Brandon regional hospital has the largest morgue in the area. I’m sure thousands of medical errors go unrecognized due to hospitals declining autopsies & families not being able to afford them. That’s why this hospital was quick to decline.

Janice

Too bad this poor guy and daughter didn’t just up and leave for another competent hospital! Soooo sad!

Emily

I’ve heard that some hospitals scare patients, because they say that if the family switches hospitals that they will be stuck with bills. 🙁

Linda Haller

We need to take a look at our state legislators. Why would any public servant work to pass a law that was detrimental to their constituents? Clearly their constituents do not benefit from laws that promote zero accountability. What’s in it for the our legislators? Clearly, there is nothing that benefits the public.
A very simple solution: CMS payments should be determined by the reduction in preventable medical error. We’d see it go to zero in no time.

Julie Griffin

There have been numerous attempts to change this law, however, many politicians are “obligated” to vote according to their high influence donor class. Just this year a bill was never heard before the FL senate and Fl Chamber of Commerce actually emailed all the Fl house members and threatened them if they voted in favor to change this law.

Emily

Oh my gosh, revenue stream rules and those in the trenches suffer 🙁

nursey

Wondering what the hospital was doing to silence the daughter ! How can a true story be silenced ? Very sad. ! And who passed this law ? what about the grd son who is under 25 ? doesn’t count . This is called not listening to the patient .

Sabrina

The truth will always come out. No threat from them will ever silence me.

Sabrina

Florida is afraid of losing their health care providers if they change the free kill law but truth is, they are going to lose their health care providers if they DONT change this law. I have no desire returning to the medical field if it means working with incompetent Drs. who get away with such negligence.

I’m so thankful for Bob & the hospital watchdog for bringing this tragic, heart shattering story to light. My Dad fought for this country. He did not deserve this. Time to fight for accountability.

Julie Griffin

I’m so very proud of you for continuing the accountability fight.

Katrina Stack

This is my good friend Sabrina. Her Father was an amazing, supportive man and would help anyone who needed it. He was very self sufficient, worked on cars, everyone in town knew him. I still do not understand how knee pain turned into death? I have witnessed Sabrina’s struggles through this senseless act of disregard for human life. I’m so glad her voice can be heard despite Brandon hospital attorneys trying to silence her. The reasons are apparent and I see other reviews from upset families, why did they try to silent her? There is so much more to this… Read more »

Sherry

This is so wrong. How can a person who has taken an oath to do everything to the best of their ability in caring for their patient neglect that patient’s needs? A simple ultra sound was all that was needed to be ordered to determine that this patient had a blood clot, he could have received appropriate treatment and walked out of the hospital alive and well. What a tragedy! A tragedy that could have been avoided! I feel very sad for my daughter Sabrina and my grandson. It’s unfair that this dr. or these dr.’s cannot be held accountable… Read more »

Sabrina

Here is a photo of my Dads left leg just days before he went to the Brandon ER..
anyone who thinks that “physical therapy” will treat this is a danger to the American patients.

0023D6AE-20F4-482B-ACB4-D6F8E77A5AAC.jpeg
Emily

Another eye opening article. I especially resented how this hospital attempted to threaten the daughter. Seriously, any other developed country’s healthcare system would be so much better. I’ve felt threatened by a facility myself after a family member’s harm. Politicians need to do something!

Rebecca

My deepest sympathy goes out to Sabrina. What a terrible shock to hear the news about your father’s code blue situation only minutes after talking with him. I have experienced my own horrors in the ER with a loved that I nearly lost because of system errors. The aftermath of the case has been very difficult to manage and overcome. Telling your story is important for your own catharsis and to mitigate such an event happening to others. Have you tried contacting the hospital’s executive team? Sometimes they are willing to meet with families to learn how they might change… Read more »

Sabrina

Thank you Rebecca. I have made the hospital aware, they sent me a letter stating they would use my Dads death to “help educate staff”.. that was a slap in the face for me as I have gone to college & paid tuition, I paid to learn what I know. In this case my Dads life/ death is being used to educate Brandon regional hospitals incompetent & under educated staff.
Thank you for the prayers, definitely needed

Nursey

wow ! and who sponsored this law ? This article did not say but was the medical board involved ? Most boards if they act on a license will not to protect hospitals but since the hospital cannot be sued , maybe they will act . Sad .

Sabrina

The law was made back in 1990. We all know someone who is divorced/ single/ widowed & have children over 24. We all know a Florida “free kill” person. Why does Florida send all the elderly here? So they too can become free kills? The law needs to be changed. I was unaware of this law prior to this happening. If I am expected to take responsibility of someone slips on my front porch then these Drs should damn sure have to take responsibility for violating the oath they took & causing my Father to succumb to a situation where… Read more »

Guy Jones

Wow. This is a disgrace. Even an EMT, forget an MD, or somebody with minimal medical training, can tell that this man had a BLOOD CLOT IN HIS LEG. This is like a horror movie. Water on the knee? This is like a clown show. Then physical therapy and when the man stands up, the DVT travels to his lungs and kills him. OMG this is unacceptable. This wasn’t some strange, wild, rarely ever seen event/disease or some rogue blood clot that formed after a surgery and went immediately to the heart or lungs. He was in the hospital for… Read more »

Last edited 3 months ago by Suzan Shinazy
Susanna L Harris

I am so incredibly sorry for your loss. Florida’s Free Kill law must be defeated.

Sabrina

It must be, before more people keep getting killed & the one at fault gets away with it. Why is this the elderly capital of the world? What about people with disabilities who have little to no chance of marriage or having children? So many fall in to the free kill category. It’s cheaper to allow someone to die than it is to save them knowing they can sue if they live, but no one can if they die.

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