Mike and Carol Bradley were happily married for 46 years. At age 72, Mike was still working full time as a car salesman. He was excellent at his job and popular in the community. An avid reader, he accumulated piles of books at home. He and Carol enjoyed going out dancing together and attending music concerts. He was a good man.
Mike was generally in good health. However, his cardiologist informed him that one of his cardiac valves would need repair down the road. Rather than put it off, Mike decided to go in for elective, noninvasive, mitral valve repair. He was told it would be best to do the procedure earlier rather than later, as a preventative measure while he was relatively healthy. As a registered nurse, Carol wholeheartedly supported his decision and knew this to be a relatively routine procedure.
After the procedure, they were told it went well. But when Mike got to the ICU for recovery, he began to have seizures due to brain swelling caused by an air embolism. He went into a coma for nine days. She was told by hospital staff that this simply “happens sometimes,” even though there was no mention of the risk of an air embolism before surgery.
By the time he awoke from the coma, Mike had lost his ability to swallow. Standard practice in such cases is to remove excess fluids by suction, because they can accumulate in the respiratory system and cause pneumonia. Mike’s nurses repeatedly neglected to provide this care, even when it was clear from gurgling sounds he was making that he needed it. Carol had to repeatedly ask nurses to suction Mike, and they even deferred the task to her. Mike soon developed pneumonia.
During treatment for the infection, he was given a feeding tube. The tube was clipped to his hospital gown, against standard safety protocols, and he accidentally moved it during the night. The staff then failed to evaluate and monitor his condition according to hospital protocol resulting in massive hemorrhaging, sepsis, and complete kidney failure. Carol had to make the devastating decision to remove her husband from life support.
During his time in the hospital, Carol was constantly at his bedside, keeping an eye on his care. She had been told multiple times by staff that the hospital was shorthanded and she noticed that those on staff were recent graduates. She thought Mike’s care was dangerously sub-standard. A nurse herself, she advocated for Mike night and day, catching significant errors. She felt that no matter what she did, she couldn’t protect Mike from the problems that continued to occur.
After Mike’s death, Carol also filed a complaint with the Medical Board of California. Only a few months later, while Carol was deep in grief and struggling with PTSD, she received a form letter from the Board. It said that the physician’s assistant responsible for Mike’s care would not face disciplinary action. This was shocking, especially because the California Department of Public Health had already investigated and found a substandard level of care and issued their highest disciplinary level—level four immediate jeopardy.
Carol felt even more deeply disappointed and betrayed. By allowing the physician’s assistant to move on without penalty, the Board disregarded her husband’s death and put others’ lives at risk. She felt that the Board had failed in its sole mission to protect the public. She wants to see reform, like creating a public member majority and an improved investigation process that includes patients and their families.
