The Silent Treatment

Because state law allows hospitals to keep their mistakes secret, James Williams may never know exactly how his wife went in for routine surgery and came out in a coma

Fairview officials bristle at the notion that the hospital withheld information. "We gave them all the information there is about their family member. Your goal is to make sure everyone knows what's going on and that the family does not feel excluded," says Margaret M. Van Bree, chief operating officer of Fairview-University Medical Center, adding that physicians sat down with the Williamses and painstakingly went over Sharon's medical record step by step to explain it. "But it is an unexpected event. There may be questions that we don't necessarily have answers to right away."

The first details of what had happened in the recovery room, Williams says, came from a doctor, unaffiliated with Sharon's care, who had been in the room when the nurses tried to resuscitate Sharon. This doctor, Williams says, called him and talked to him for about 40 minutes, not because he had anything to do with Sharon's surgery, but as a concerned person who was also upset. "He told me that my wife's alarm system was never activated. He said human error was involved. Somebody forgot to do what was required," Williams remembers. "If he hadn't told us, we would not have known today. It was not the institution that disclosed that."

More information would come to light, though, again, not directly from Fairview. The Minnesota Department of Health looked into the incident. Investigators reviewed Sharon Williams's medical charts and visited Fairview-Riverside on three separate days in July, interviewing the staff on duty during the incident. These investigations are generally triggered by a complaint filed with the state; not every complaint is deemed serious enough to warrant an investigation, and not every investigation substantiates the complaint. In this case, however, the Department of Health began its own inquiry after seeing news reports about Sharon Williams.

On September 18 the health department issued a report on its investigation. When Williams read the document, it was the first time he learned the details of what had transpired in the recovery room. According to the report, Sharon Williams, who was then 42, had been in good health prior to her surgery. The operation went smoothly, without complications.

After the procedure, the agency concluded, Williams began to wake from the anesthesia. At 3:17 p.m., she was transferred from the operating room to the recovery room. She arrived at 3:20. "Documentation reflected that her vital signs were stable," the report notes. "Her oxygen saturation was 100 percent, she was moving all extremities, and was responding to and following commands." Williams was one of three patients in the recovery room; there were three registered nurses working, and each was assigned to one patient.

A registered nurse, the report explains, must assess the patient when she arrives in the recovery room, evaluating her breathing and circulation. The nurse is then responsible for connecting the patient to a monitoring device and engaging alarms that sound if her vital signs or breathing drop below an established guideline. The nurse is also responsible for assessing the patient's level of consciousness and pain.

The nurse in charge of Williams's care did, in fact, assess her at 3:20 p.m. (The nurse, who is not named in the report, still works at Fairview-Riverside facility.) Williams was moaning slightly from pain and could move her feet and take deep breaths when asked. The nurse hooked Williams up to an oxygen line and placed a blood-pressure cuff on her. The nurse, the report continues, recalled that she then "hooked her up to the monitor, but I failed to push the button to engage the alarm." Without the alarms, the monitor would not alert staff to changes in Williams's condition. At 3:25 p.m., the nurse administered four milligrams of morphine to ease the patient's pain (an effective pain medication, morphine causes breathing to slow down). She listened to Williams's lung sounds, noting that they were somewhat decreased, then left Williams and "walked over to talk to another nurse." She estimates that she had her back to the patient for less than three minutes.

The report is less specific about what took place during the next 15 minutes. Another recovery-room nurse came to consult with Williams's nurse, who was getting ready to go on break. The second nurse looked at Williams's monitor and saw that her heart rate and blood pressure were low, and that she was not moving. Williams's nurse engaged the monitor's alarm, which immediately sounded. The two tilted the head of Williams's bed downward 30 or 40 degrees to increase blood flow to her brain, gave her more fluids, and raised her chin to establish an airway.

Documentation about the incident noted that at 3:40 p.m. an anesthesiologist who was coincidentally walking through the recovery room noticed that Williams's head was tilted down, that she was unresponsive, and that she was not breathing. The anesthesiologist, who was not involved in Williams's surgery, began ventilating Williams with an air bag. "Although the anesthesiologist was unable to estimate the exact length of time that [Williams] had been without respiratory exchange, he did indicate that it had been more than just ' had been minutes,'" the report states.

While all this was happening, James Williams sat in the waiting room, trying desperately to find out how his wife was.

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