I have been struggling with something for quite a while, not speaking much about it, holding it close and trying to come to terms on my own. It has been a lonely, difficult and painful struggle.
I’ve been praying for help with acceptance and yet a part of me feels as if I’m giving up. My nature has always been such that when I know something is wrong I dig in and keep at it until it’s made right. Like a dog with a bone, don’t try to take it from me….I fight.
At least I used to.
I retired for a number of reasons, one of which was that I was discouraged. It was feeling like the legal system wasn’t about accountability and justice but “let’s make a deal”.
That fact became crystal clear in a very personal matter and that’s part of what I’m struggling with now.
Sister #3 died unexpectedly May 10, 2016. The fact that she died, while painful, is not what I’m struggling with. Death is a part of life after all. It’s the reason she died that I’m still struggling with.
She was hospitalized for difficulty breathing and coughing up blood. At admission her oxygen was at 84 or 85% and she had a heart rate of 124. It took four days on oxygen for her levels to reach 95% and she felt so much better. At that point her oxygen was decreased to see how she’d do. Overnight, just sleeping, the next day her levels had dropped to 93% but that was good enough to get her discharged. It didn’t matter that with no activity, just decreasing the oxygen, her levels dropped. She was discharged.
At her visit with her primary care provider three days later her oxygen levels were at 91%. Still decreasing, but not much was said about that, maybe because she had an appointment with a lung specialist five days later.
She met with the specialist. An oxygen reading was taken. We don’t know what the first one was, but she told my sister they had to rub her hands to warm them and then took another reading. That reading showed her oxygen was at 85% and her heart rate was 132; eight days after her discharge from the hospital for the exact same issue. The doctor told her he’d schedule a sleep apnea test and a Cat Scan for two to three weeks later and she was sent her on her way. He he did not tell her she needed to return to the hospital or even prescribe oxygen to use at home while waiting for further tests. Two simple actions that I, as a lay person, would consider reasonable care. She trusted the doctor.
She collapsed two days later, not living long enough to have those tests done. She was 59 years old.
This is where I’m struggling.
We filed complaints with the State’s Office of Professional Medical Misconduct. That agency’s website’s definition of medical misconduct included “abandoning or neglecting a patient in need of immediate care”. How much more immediate was an oxygen level of 85% and a heart rate of 132?
The results of our complaint?
We received a letter before Thanksgiving advising that upon completion of the investigation there was not sufficient evidence to bring a charge of medical misconduct as defined by the State’s Education Law. The letter stated the investigation was closed. However, a permanent non-public file of the case will be maintained for future use as needed.
Translation: because no other complaints had been filed against the doctor our complaint becomes a non-public record for future use in the event there is another complaint. How many average people know anything about this Agency? We didn’t until a lawyer suggested we file our complaints.
And that brings me to the legal system; justice and accountability. I picked up my sister’s records from the Attorney’s office the other day. The bottom line came down to dollars and cents.
Because my sister was on Social Security disability for a diagnosed mental illness and wasn’t a wage earner, there wouldn’t be a value to pursuing a wrongful death suit. Wrongful death is basically based upon the potential value of the lost wages of the individual. Also, because she had difficulty with drinking in the past, that fact together with other issues would make a malpractice lawsuit lengthy and expensive. The defense would use those issues….defending which would prolong the legal process. The expenditures for a legal action would probably exceed any potential award. This was the advice provided by the attorneys we spoke with.
If there had been a finding of professional medical misconduct that would change things but no other complaints had been filed so no finding of misconduct.
The last attorney, while very sympathetic, also declined to accept the case. A recommendation was provided in the event we wanted to seek yet another opinion.
A life lost and it comes down to dollars and cents not accountability.
This is the one and only time in my life I have wished to be wealthier, to have the money to pursue something that requires a good deal of money. Accountability shouldn’t come with a price tag.
As I said, during this whole process I’ve been praying for acceptance because a part of me still feels like I’m giving up. I asked Sister #4 what the difference was between acceptance and giving up. She said acceptance is knowing you did everything you could; giving up is bitching about what happened but doing nothing. In my mind I know we’ve done all we could but my heart still aches with trying to understand how this could have happened especially in this day and age.
My husband reminded me that my sister was a very loving, kind, generous woman, always there to help whoever needed help despite all she had to deal with personally. Her non-public record is there, waiting to help the next family. I pray there will never be a “next time” for anyone else. What he said is so true and I’m trying to take solace from that. I’m trying to let go of the feeling that I’m giving up, to hold on to what my husband and sister said.
It hasn’t been easy, but I’m hoping that with the writing and mailing of my final letter to the State Agency and writing and sharing this story, I’ll be able to finally let go of the heartache and anger I’ve held on to for so long and focus, instead, on the memories and the love we all have for our sister.
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