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Nurse Urged To Cover-Up Fatal Medication Errors

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Statement From Shirley Barker, RN, BSN:  

Retired RN, Shirley Barker
Retired RN, BSN, Shirley Barker

As nurses, we’re expected to be the “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 that led to harm and even 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 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 Nelson Yamamoto, a patient she cared for in a Surgical ICU. Mr. Yamamoto was a Los Angeles Sheriff’s Deputy 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.

(The following interview with Nurse Barker was edited for clarity and brevity.)

Sheriff’s Deputy Shot By Murder Suspect

 Sheriff's Deputy Nelson Yamamoto
Nelson Yamamoto, Age 26

By Bob Aller:  November 6, 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 ran out firing at the officers as they tried to escape. Deputy Yamamoto returned fire. A suspect, Isidoro Ibarra, 30, died in the gunfight. However, Officer Yamamoto suffered potentially fatal wounds from .357 shots in the abdomen and shoulder. He was rushed by ambulance to the nearest trauma center, the Martin Luther King Jr./Drew Medical Center, a Los Angeles County 480-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: My weekend was Saturday through Monday. I came onto my Tuesday 12-hour shift at 7 am to care for Mr. Yamamoto. He was my only patient. 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 had kept his blood pressure in safe limits, around 140 over 80. Pretty decent for the circumstances. 

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 the Chief General Surgery Resident, Jonathan Heard, arrived at Mr. Yamamoto’s bedside with a first-year resident, Charles Jones. They both were in 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 described how he was clearly trending in the right direction.

Q: Did Dr. Heard alter Mr. Yamamoto’s medication regimen?

A. Nurse Barker: After I finished describing 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. Only moderately 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 anyone object to Dr. Heard’s plan?

A. Nurse Barker:  Dr. Jones, the first-year resident who was also standing at the bedside, spoke up: “I believe titrating down the Epinephrine drip would be best.” I completely agreed with Dr. Jones, hoping Dr. Heard would consider Dr. Jones’ opinion. Instead, Dr. Heard resented Dr. Jones’s comment. I recall he said: “Shut up, if you know so much, I wouldn’t be here.” That was a tense moment. I believe Dr. Heard meant he thought he was smarter than Dr. Jones. 

I recall that Dr. Heard then sat down at the desk. He made a short phone call. Since our ICU was a noisy area with monitors beeping, phones ringing, staff talking, I could hear the sound of his voice but I didn’t hear what he said. It was very brief. I don’t know if he consulted with his attending or anyone else.  

Dr. Heard then went ahead and pushed in the Verapamil with an IV. I started documenting vital signs so I would have a baseline to Nelson’s response to the Verapamil. However, there was little or no response.

As a resident, Dr. Heard would often consult with the Director of the ICU, Dr. Meade. I found it odd that he didn’t consult with Dr. Meade, who was also nearby in the ICU.

Maybe about 15 minutes passed without a change in the 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 indicating he wanted me to administer another medication, Labetalol. I was opposed to Labetalol. I thought it was too risky. He gave me a look that said you’re going to administer Labetelol, aren’t you? I made my decision. I said: “I’m not going to do it.” This was the first time in my nursing career that 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.
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 the adverse 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 frightened all of us.
 
Suddenly, the alarm system went off. It was loud. Dr. Heard tried to turn off the alarm but it was stuck and he couldn’t turn it off. Dr. Heard moved quickly to initiate CPR.
As I rushed to get the crash cart I saw the Director of the ICU, Dr. Meade, making rounds. I told him what drugs were used.  He said: “Oh, no!”
Dr. Heard and others tried everything to save Mr. Yamamoto’s life. Their efforts went well beyond the normal amount of time allowed for reviving a patient. Mr. Yamamoto could not be revived.

Q. What happened to Mr. Yamamoto’s chart?

A. Nurse Barker:  After Mr. Yamamoto was declared dead I went to enter that information into 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 others may have 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 devastated, 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. 

Hospital Covered Up Cause of Death

The hospital’s Medical Director informed the press that Nelson Yamamoto’s death was due to gunshot wounds. The Autopsy Report from a Deputy Medical Examiner states the patient died from “multiple gunshot wounds.”

Autopsy Report for Nelson Yamamoto
Autopsy Report for Nelson Yamamoto

However, the toxicology report in the Autopsy omitted Epinephrine, Verapamil and Labetalol.  These medications were administered just before Mr. Yamamoto’s death. According to a physician consulted by Hospital Watchdog, the Autopsy Report’s conclusion that “multiple gunshot wounds” constituted the “immediate cause” of death was reached without the required information for a toxicology report. This omission suggests the hospital may not have provided the medical examiner with critical chart notes and medical records. Alternatively, the medical examiner may have received that information but he made the decision to ignore it.

(See Autopsy Report)

A Hero’s Funeral 

An estimated 4,000 uniformed officers traveled from throughout Southern California to attend Mr. Yamamoto’s funeral with family and friends. 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, was a fitness devotee, and was engaged to be married to schoolteacher Michelle Tomi.

Complaint Filed 

Days after Mr. Yamamoto’s death, a credible complaint was filed with the Sheriff’s Department. The complaint, perhaps submitted by another hospital employee, alleged Mr. Yamamoto did not die from gunshot wounds. What followed was an escalating investigation lasting three years. Three government agencies participated: the Los Angeles Sheriff’s Homicide Division, the Medical Board of California, and the Los Angeles County District Attorney.

Early in the investigation, doctors’ attorneys strongly objected to aggressive DA interviews, conducted without a lawyer present. To counter the doctors’ reluctance to testify, the DA empaneled a Criminal Grand Jury.  

All the doctors and nurses involved in Mr. Yamamoto’s care, including Dr. Heard, Dr. Jones, and Nurse Shirley Barker, were subpoenaed.

A senior hospital physician was reportedly designated by the administration to manage this high-profile case as the attending. However, Dr. Rosalyn Sterling Scott took the 5th and would not testify. She denied she was the attending physician. She claimed there was a misunderstanding, she only helped out temporarily.

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. 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 with them. 

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 will 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 in and testified before the Grand Jury to exactly what I observed in the ICU. 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 and gave me a hug. He thanked me for telling the truth. Since Dr. Jones had also testified before the Grand Jury, I thought he may have learned he had been targeted as the “fall guy.” But that didn’t happen.

District Attorney Report Issued in 1995

Finally, in July of 1995, the District Attorney’s office issued a 160-page report, concluding that Dr. Heard had administered a lethal combination of cardiac drugs to Mr. Yamamoto. One of the report’s medical experts claimed the deadly error could have been avoided by checking the standard physician’s reference manual.

In addition, the report revealed that “progress notes” had been found missing.

According to the LA Times, District Attorney Gil Garcetti concluded there was sufficient evidence to charge Dr. Heard with involuntary manslaughter. However, Mr. Garcetti chose not to file an action. He thought it was unlikely a jury would convict a physician in this case. Nevertheless, the California Medical Board did require competency testing for Dr. Heard. He passed the test.

King/Drew Hospital Closed Forever

Los Angeles 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.” 
Hospital Watchdog filed a Public Records Act request for the 1995 Los Angeles County District Attorney’s Report on the death of Nelson Yamamoto. However, 25 years after the report was written, the DA’s office was unable to locate the report. The Los Angeles Times reported it had obtained a copy of the DA’s report for its news articles. Hospital Watchdog has relied on a number of details from the LA Times reporting on this case.
Nurse Barker made a studious effort recalling events from nearly 30 years ago. However, she acknowledges that some small details she recalled may not be quite right. Nevertheless, the main thrust of her recall is accurate.
If you have any additional information about the case of Nelson Yamamoto, please contact Hospital Watchdog through our contact page.

 

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