Cases Reveal Lapses In Emergency Care

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Los Angeles Times

The Kaiser Permanente doctor who examined Harun Antwine had worked at least 10 hours that day, seeing 25 patients in his office and 15 more that evening at the HMO’s Fontana urgent care center.

The swamped physician didn’t spot Antwine’s serious bacterial infection, and the 29-year-old patient left urgent care without antibiotics, Antwine’s family lawyer says. The father of three young children died two days later.

“It was a classic case of failing to treat a patient [who] really needed it,” said lawyer Gregory Patton, who won an $848,000 arbitration award from Kaiser stemming from Antwine’s 1998 death. “Their doctors are really, really overworked.” In justifying a $1.1-million fine against Kaiser, state regulators cited three patient deaths and said the cases demonstrated a pattern of problems in emergency care that has put the HMO’s 6 million California members at risk.

Similar problems showed up in at least nine other cases since 1995–including Antwine’s–in which arbitrators found Kaiser liable for patient injuries or deaths.

Although the number of arbitration awards is small, and Kaiser calls the cases anomalies, critics say they illustrate the same dangers identified by state officials: not enough staff and overcrowded facilities.

Kaiser, the state’s largest HMO, denies that it has systemic problems and argues that the state’s HMO czar, Daniel Zingale, has overstepped his authority. It is challenging the fine, which was imposed in 2000 and was increased last year.

Moreover, Kaiser said the arbitration awards reviewed by The Times should not be considered a pattern, given the millions of patients who seek care through the HMO.

“These cases are obviously things that everybody wants to pay attention to,” Kaiser spokesman Jim Anderson said. “But to suggest anything other than that they represent [nine] individual medical malpractice cases is stretching a long way, we think.”

Arbitration awards, though relatively rare, are among the few public avenues available for examining patient complaints against Kaiser. Dissatisfied Kaiser patients seeking damages must go through arbitration, because the HMO requires enrollees to waive their right to sue.

According to the nine arbitration summaries, Kaiser has been ordered to pay more than $3.5 million for lapses in emergency or urgent care since 1995.

That amount represents only a fraction of what Kaiser has paid out in cases that were settled and sealed from the view of the public and HMO regulators, patients’ lawyers say. Kaiser has settled nearly half of its recent arbitration cases, records show.

The nine cases reviewed by The Times include those of:

* A 39-year-old diabetic woman who died after her chemical imbalance went undetected by an urgent care doctor in Lancaster.

* A 6-year-old boy who died in the hospital after the Kaiser urgent care center in Panorama City failed to diagnose a heart ailment.

* A 64-year-old man who died of an undiagnosed ruptured abdominal aortic aneurysm at the Woodland Hills urgent care center.

* A 41-year-old man who went to Kaiser‘s Panorama City emergency room, where his chest pain was attributed to yardwork. The man visited Kaiser facilities twice more before dying five days later of a heart attack.

Anderson said the nine arbitration awards involved different facilities, different patient symptoms and different outcomes. He said Kaiser has 11 emergency rooms in Southern California that see 800,000 patients a year and that many more people visit urgent care centers.

The arbitration cases also span a significant period of time, Anderson said. Though all were decided since 1995 and most involved incidents in the last decade, one dates to 1987. Arbitration cases can take years to resolve.

Kaiser argues that even if everyone does their best, patients sometimes die.

That, Kaiser claims, is what happened in the case of Antwine, the 29-year-old who died of a bacterial infection.

When the patient arrived at the urgent care center, arbitration filings say, he wasn’t exhibiting typical symptoms of a strep bacterial infection. Even if he had been given antibiotics, the HMO said, Antwine would have died.

Critics say such cases should not be viewed in isolation. In fact, the state findings and the arbitration claims are, in some instances, remarkably similar.

Two of the cases won in arbitration involved patients who died of undiagnosed abdominal aortic aneurysms, the problem also found by the state in its investigation.

In their fine, state regulators cited the case of Wolfgang Spunbarg, a 72-year-old enrollee who went to the Woodland Hills emergency room in April 2000 complaining of severe pain in his abdomen and testicles.

According to the hearing testimony of Spunbarg’s wife, Edith, she pleaded with the ER receptionist to have someone examine her husband immediately but was told that the ER was too busy and that she would have to wait.

About 15 minutes after arriving, she burst into the examination area of the ER and demanded that a doctor see her husband. Moments later, he fell unconscious; he died within two hours of an undiagnosed abdominal aortic aneurysm.

According to filings in a separate arbitration case, Gery Lichtig, 64, had gone to the urgent care center at the same hospital 13 months earlier, complaining of serious abdominal and back pain. As in the Spunbarg case, Lichtig’s wife, Temah, pleaded with the receptionist to call a physician.

After being seen by a nurse, Lichtig waited 45 minutes, retching in pain, according to the arbitration filings.

On his way back from having X-rays taken, the documents state, Lichtig leaned back in his wheelchair and screamed, “The pain, the pain!” His eyes then rolled back, and he fell unconscious. He died less than three hours later, also of a ruptured aneurysm.

Temah Lichtig said the state’s findings were like a horrible echo of her own experience with Kaiser.

“The state is so accurate in everything that they’re saying,” she said. “They’re just calling it like it is.”

Kaiser is challenging the $1.1-million fine before an administrative law judge, claiming that Zingale does not have the authority to regulate care provided by its hospitals and doctors. Testimony resumes this month in Oakland.

Defending the fine, Zingale said the California Department of Managed Health Care found that Kaiser doctors and nurses failed “to communicate . . . the seriousness of a patient’s condition and the need for a rapid response.”

He said some of the claims raised in the arbitration cases reviewed by The Times seem “of a similar nature to what we’re looking at.” But the cases were not cited in support of the fine because they alleged individual instances of medical malpractice, not systemic problems.

Several patients’ lawyers said they did not allege systemic problems, because winning individual malpractice cases does not require proof of widespread flaws.

The plaintiffs’ lawyers say Kaiser‘s problems are more extensive–and the real toll paid by the HMO is far higher–than the public record suggests. The awards obtained through arbitration reflect only those cases in which a verdict was reached, not those settled confidentially.

Kaiser declined to discuss the number of cases that it has settled or their amounts.

“There’s systemic problems with everything they do,” said Bruce Levenson, a Beverly Hills lawyer who represented the family of the diabetic woman who died. “I think they give you as little care as they possibly can. . . . They cut corners.”

Anderson, however, said Kaiser is more likely than other HMOs to be targeted by arbitration complaints because it owns its hospitals and works primarily with one doctors group. As a result, patients associate quality of care with the HMO itself.

Kaiser is also more likely to face action related to the quality of patient care from state HMO regulators, as Zingale himself acknowledges.

But some lawyers and family members who have won arbitration awards against Kaiser say they only wish its flaws had come to light sooner.

“I want to help bring this awareness to other people so Gery’s death will not have been in vain,” Temah Lichtig said. “This man did not have to die.”

Kaiser argues that he could not have been saved.

“People can do their very best and do everything right and do superhuman efforts, and the patient will still suffer a bad outcome,” Anderson said. “That’s just a sad fact of medical life.”


Times researchers John Tyrrell and Scott Wilson contributed to this report.

Arbitration Awards

At least nine times since 1995, arbitrators have found Kaiser Permanente liable for lapses in care provided to patients at its emergency rooms and urgent care centers. Arbitration cases sometimes are decided well after the alleged lapses occur.


Arbitration award: $350,000

Claim: Kaiser should have hospitalized a 43-year-old woman with asthma when she went to the emergency room in Riverside in January 1993, complaining of fever, shortness of breath and other problems. Instead, the hospital sent her home. She died the next day after returning to the emergency room with respiratory distress.


Arbitration award: $325,000

Claim: Kaiser failed to diagnose a heart problem in a 41-year-old gas station owner who went to the emergency room in Panorama City with chest pain, sweating and arm numbness in 1994. Doctor attributed muscle pain to yardwork and sent man home. He returned to Kaiser twice before he died June 10 of a heart attack.


Arbitration award: $500,000

Claim: Kaiser failed to prescribe antibiotics to a 4-year-old child who went to the Anaheim emergency room with fever, nausea and joint pain in February 1987. The child developed bacterial spinal meningitis and became deaf as a result of the condition.

Arbitration award: $257,190

Claim: Kaiser Bellflower emergency room failed to hospitalize a 48-year-old woman who complained of chest pain, low blood pressure and anemia in 1993. She died four days later of a ruptured abdominal aortic aneurysm.


Arbitration award: $848,000

Claim: Kaiser urgent care center in Fontana failed to treat a bacterial infection in a 29-year-old food service manager in March 1998. Physician discharged him despite high fever and inability to walk. He died of complications from the infection.

Arbitration award: $250,000

Claim: Kaiser urgent care center in Mission Viejo failed to remove glass from the knee of a 9-year-old girl who struck a glass cabinet door in May 1995. Glass was removed surgically more than two years later, causing cartilage damage.

Arbitration award: $407,000

Claim: Kaiser urgent care center in Panorama City failed to diagnose a viral heart ailment in a 6-year-old boy who sought medical care in May 1994. Although he was admitted to a hospital, the boy died several hours later.


Arbitration award: $375,000

Claim: Kaiser urgent care center in Lancaster failed to diagnose a chemical imbalance and dehydration in a 39-year-old diabetic woman who sought help in January 1999. She was discharged and died hours later.

Arbitration award: $354,500

Claim: Kaiser urgent care center in Woodland Hills did not diagnose a ruptured abdominal aortic aneurysm in a 64-year-old man who died while seeking care in March 1999.

Source: Times research, including Verdictum Juris Press, Jury Verdict Weekly, Verdicts on Disk, Confidential Report for Attorneys

GRAPHIC: PHOTO: Tehah Lichtig’s husband died in a Kaiser wheelchair of an undiagnosed aneurysm. She hopes her arbitration award saves others. PHOTOGRAPHER: BRIAN VANDER BRUG / Los Angeles Times

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