Charlene Murphey Death Certificate Questioned
Bob Aller Revisions: March 12, 2019. Posted: March 9, 2019.
The tragic death of Charlene Murphey at Vanderbilt University Medical Center has been widely reported in the media. Recently, Hospital Watchdog received a copy of Charlene Murphey’s Death Certificate (#09801569). The date of death is December 27, 2017. (Out of respect for the privacy and feelings of the Murphey family we are not posting the Death Certificate.)
The Death Certificate also bears the name of Vanderbilt neurologist Eli Zimmerman. He certified that Charlene Murphey’s MANNER OF DEATH was NATURAL.
However, the Centers for Medicare and Medicaid Services (CMS) identified substantial evidence refuting Dr. Zimmerman’s claim of a NATURAL death. CMS reported that the underlying cause of Charlene Murphey’s death was the medication vecuronium. Vecuronium caused suffocation, cardiac arrest and other complications leading to death. In addition, CMS revealed that Vanderbilt violated Tennessee law by failing to properly report this tragic event to government oversight entities for a period of ten months.
Whistleblower Files Complaint
The unraveling of this cover-up began in October 2018 when a whistleblower filed a complaint with the Tennessee State Department of Health. The complaint triggered an on-site investigation. In November 2018 CMS issued a 56-page Summary Statement of Deficiencies.
VUMC Knew Within Minutes
The CMS report cited interviews with Vanderbilt nurses and doctors, medical records, and the physical evidence of leftover vecuronium. The CMS report revealed that Vanderbilt hospital staff knew within minutes that a medication error had caused this fatality.
Just minutes after the medication error, Nurse RaDonda Vaught explained to hospital staff that she accidentally gave vecuronium to Charlene Murphey. Over a year later, in February 2019, Nurse Vaught was indicted by a Nashville Grand Jury for reckless homicide. Yet, the death certificate, a legal document admissible in court, states Charlene’s manner of death was natural.
Dept. of Health Definition: Death Was Unnatural
The Tennessee Department of Health defined why Charlene Murphey’s death cannot be viewed as a natural death. If a discrete injury or poisoning event contributed in any way to death, regardless of time elapsed between the event and death, the manner of death cannot be considered to be natural. After receiving the accidental dose of vecuronium at about 3 PM on December 26, 2017, (thought to be Versed), Charlene was left alone in a patient waiting room for a PET scan. The patient was not monitored. Charlene was discovered about 30 minutes later. Unable to breathe, she was found non-responsive. She had suffered cardiac arrest and partial brain death. After CPR, Charlene was put on a breathing machine for approximately 10 hours. Finally, she was removed from the machine. Charlene passed at 1:07 am on December 27, 2017.
Did A Vanderbilt Doctor Mislead The Medical Examiner?
Under Tennessee Code T.C.A. §38-7-108, when a death occurs in any suspicious, unusual, or unnatural manner, the doctor is required to notify the county medical examiner to investigate the death. When an unnatural death occurs, the Medical Examiner is required to determine the facts and complete the death certificate. CMS interviewed the Director of Investigations (DOI) at the Medical Examiner’s Office. The DOI reported that the Vanderbilt doctor had said that “maybe there was a medication error but that was just hearsay, and nothing has been documented in the medical record. There was no named drug in the notes.”
Nevertheless, CMS identified a medical record for vecuronium in the Automatic Dispensing Cabinet (ADC) detail report at 2:59 PM on December 26, 2017. The record showed that Nurse Vaught obtained the medication vecuronium from the cabinet. In addition, Nurse Vaught fully admitted within minutes that she had mistakenly administered vecuronium.
Doctor Claims No Recollection Of Conversation With Staff From Medical Examiner’s Office
CMS interviewed the Vanderbilt doctor (physician #3) who spoke to the Medical Examiner’s Office. The Vanderbilt doctor said he had no recollection of the conversation with the Medical Examiner’s Office. In addition, the doctor failed to make chart notes summarizing the conversation.
The Medical Examiner’s Director of Investigations told CMS that the Vanderbilt doctor said there was “hearsay” about a medication error. However, the CMS report found that the use of vecuronium was not “hearsay.” It was widely known to hospital staff for approximately ten hours before Charlene passed and before the Medical Examiner’s Office was contacted.
The Medical Examiner’s Office confirmed to CMS that the office would have accepted this case if it had been informed that vecuronium was accidentally administered. By providing incomplete, misleading or false information to the Medical Examiner’s office, the Vanderbilt doctor effectively thwarted an investigation and an autopsy. An autopsy would likely have tested for the presence of vecuronium.
Another Vanderbilt Doctor Has No Recollection
According to Charlene’s son, Gary, VUMC never told the family what really happened. When interviewed by CMS, this doctor claimed no recollection of the conversation with the family. Like the previous doctor who had no recollection of what was told to the Medical Examiner’s office, this doctor repeated the practice of not making the required entry in the chart.
Vanderbilt Failed To File A Required Incident Report
Next, under state law, CMS reported that Vanderbilt had seven business days to file an incident report with the Tennessee Department of Health. That was plenty of time, but no report was filed. Hospital administrators are responsible for complying with Department of Health oversight regulations. Failing to file the incident report was a violation of state regulations.
Dr. Zimmerman Certified Manner of Death As “Natural”
Vanderbilt’s Dr. Eli Zimmerman completed the cause-of-death section of Charlene’s death certificate on January 10, 2018. Dr. Zimmerman omitted the medication error as an underlying cause of death on the death certificate. Dr. Zimmerman checked a box on the form: “To the best of my knowledge, death occurred due to the date, time, and place, and due to the cause (s) and manner stated.” Dr. Zimmerman certified that Charlene’s MANNER OF DEATH was NATURAL.
Some observers may find it hard to believe that Dr. Zimmerman did not list vecuronium as an underlying cause of death. CMS had identified at least 12 hospital staff, including the Doctor who filled out the death certificate, present during discussions that vecuronium had been accidentally administered: Nurse #1, Nurse #2 (the primary care nurse), Nurse Manager, Nurse Practitioner, Physicians #1, #2, #3, Risk Management, Clinical Staff Leader, Employee Resource Counselor, and Two Residents. When asked what staff thought caused the event, physician #2 stated: “Our leading cause was the medication error contributed to it…”
CMS also examined a Vanderbilt document distributed on January 3, 2018, seven days before Dr. Zimmerman completed the death certificate. The document was titled Patient Safety Notification Serious Safety Event Notification. … “Vecuronium 1 mg IV inadvertently retrieved and administered by RN.”
Vanderbilt Had Substantial Evidence Of Vecuronium
In summary, within minutes after the incident, Vanderbilt medical staff had substantial, even overwhelming evidence that vecuronium was accidentally administered. Dr. Zimmerman, an Assistant Professor in the School of Medicine, completed the death certificate 15 days after Charlene’s death. He had ample time to carefully review the Manner of Death and all other information required for the death certificate.
The CMS report also points to Dr. Zimmerman as one of the physicians treating Charlene Murphey. A telling question arises. Why did Dr. Zimmerman list Charlene Murphey’s Manner of Death as Natural?
Vanderbilt Issues Blanket “No Comment” On This Case
We submitted questions to Vanderbilt regarding this matter. The response: “Because this matter now involves criminal court proceedings we won’t be commenting at this time,” said John Howser, Chief Communications Officer, VUMC. Though the CMS report indicated that Nurse Vaught was terminated shortly after the incident, the report contained no indication that personnel steps were taken against any hospital administrators responsible for the cover-up.
Family Shocked Charlene’s Death Listed As “Natural”
Nearly a year after Charlene’s death, the Murphey family was shocked to learn from the media about the true circumstances of her death. The family was shocked again when they realized that the death certificate held in their hands contradicted the news reports.
Charlene Murphey & Her Family!
The report from CMS describes in lengthy detail, on multiple pages, just how Charlene Murphey would have suffered as a result of the tragic medication error. Charlene’s husband and family suffered a terrible and permanent hurt. Vanderbilt owes the Murphey family a genuine apology for not truthfully disclosing what happened. Does the Vanderbilt hospital administration have the decency to reach out to the family to fully apologize?
Surely, Vanderbilt has noted that Charlene’s son Gary had the decency to say that he knew his mother would forgive the nurse for her mistake.
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Read Vanderbilt’s Plan Of Correction Approved By CMS
[googlepdf url=”https://hospitalwatchd.wpengine.com/wp-content/uploads/VUMC-PLAN-OF-CORRECTION.pdf” ]
Footnote: In addition to the CMS reports, the following three Tennessee government publications provided background information. 1) Medical Examiner Jurisdiction, Cause & Manner of Death, and Death Certification 2) Tennessee Department of Health, Office of the State Chief Medical Examiner, County Medical Examiner Handbook 2017 3) Funeral Directors Handbook for Vital Records Registration