For those of you following the story, here's a copy of the memo that went out yesterday from the president of New York City's Health and Hospitals Corporation. That organization runs Kings County Hospital, where the incident occurred.
Subject: Death in Kings County Hospital Center Psychiatric Emergecy Room
1 July 2008
A Message from HHC President Alan D. Aviles
To All HHC Staff:
On June 19th, a 49-year old patient died in the waiting area of the Kings County Hospital Center Comprehensive Psychiatric Emergency Program (CPEP). She was found face down on the floor and unresponsive at about 6:30 a.m. Efforts to resuscitate her were unsuccessful.
A surveillance tape of the waiting area revealed that she had tumbled out of her chair onto the floor a full hour earlier. She lay there, her head under a waiting room chair. During that one-hour period, two of the hospital's security officers and an attending psychiatrist saw her on the floor. None of these individuals went to her aid or examined her condition. A nurse entered the waiting area after the patient had been on the floor for nearly an hour, approached the patient and nudged the patient's leg with her foot, as if she thought the patient might be asleep. When the patient did not respond, that nurse failed to examine the patient and left the area to summon another nurse. The second nurse examined the patient and ultimately called a team to attempt resuscitation.
To make matters worse, the second nurse falsely documented in the medical chart that she had checked on the patient within the previous 30 minutes and that the patient was ambulating and apparently fine.
The surveillance tape demonstrates otherwise.
After reviewing the surveillance tape, we notified the State Health Department, the Office of Mental Health, law enforcement authorities and other regulatory agencies about the incident and supplied them with a copy of the tape, as well as the patient's medical records.
We took immediate disciplinary action, including termination, against the staff who failed to go to the patient's aid, the nurse who falsified the chart, and certain senior managers. We issued a public statement at the time, describing the incident and the disciplinary actions taken.
As required by law, we also turned the surveillance tape over to the plaintiffs who filed a lawsuit against Kings County Hospital Center last year alleging substandard care in its psychiatric emergency department and its psychiatric inpatient units. Yesterday, the plaintiffs released the surveillance tape to WNBC-TV, which broadcast it repeatedly during its local evening news and national morning program. News stories also appeared in major daily newspapers today.
Portions of the surveillance tape also were posted by WNBC to its Web site. Anyone who views the tape excerpts will be appalled by the lack of compassion and professionalism exhibited by the five staff members directly involved.
I bring this to the attention of all staff not just because it is an incident that will receive intense public scrutiny, but because it is a shameful event - contrary to everything that we stand for -- that we must acknowledge and confront together. How is it possible that five members of the HHC family could fail a patient in our care so completely and so callously?
I do not have the answer, but I do know that we are going to muster every resource at our disposal to ensure that something like this never ever happens again. We have agreed to place ourselves voluntarily under a court order that requires close monitoring of all patients in the Kings County CPEP, with a clinician dedicated to checking on each waiting patient once every fifteen minutes. We also have agreed to use our best efforts to minimize the time that patients wait in the CPEP for release, admission or placement. I have appointed Dr. Ann Sullivan, the Senior Vice President for our Queens Health Network and a well-respected psychiatric administrator, as an interim administrator to work closely with Jean Leon to take any and all steps necessary and feasible to ensure timely and responsive emergency and inpatient psychiatric care at Kings County.
I know that HHC shoulders the heavy and difficult responsibility of providing nearly 40% of the emergency and inpatient services in our City, predominately to the most seriously mentally ill patients. I know that what occurred on June 19th does not reflect the quality of care rendered at Kings County generally or across the other facilities that comprise HHC. I know that the vast majority of staff care deeply for our patients. I know that many staff perform superbly and at times heroically every day throughout our system and that many lives are saved as a result of their hard work and dedication. And I know that one aberrant tragedy does not negate the world of good performed by HHC staff all year long.
Comment: The fact that five out of five staff members did not respond at all to the suffering and pain of the woman in front of their eyes, does not sound like it is an exception to the rule.
However, none of that can alter the brutal and shocking reality of what happened on June 19th, the sorrow and shame that it evokes, and the necessity to ensure that it never happens again.
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Having worked in hospitals and other medical care areas, I would tentatively interpret this obvious show of complete lack of compassion this way:
First - the odds are against all 5 people being essential or secondary psychopaths. I would be a bit surprised if any of them were. However, all of them were obviously ponerized to show such lack of compassion.
Second - assuming the 5 all showed signs of ponerization (pardon me if my terminology is loose), it's strongly suggestive that these 5, who worked for the same company, were exposed to the ponerization process from the company itself, or at least persons or persons within the company that they had regular contact with. - To suggest all 5 were ponerized in a way that they all showed similar lack of curiosity and compassion by influences outside the company just beggers belief.
Third - my experience as a worker in corporate culture, whether hospital, medical, or retail, has been that the corporate culture, does strongly tend to ponerize the workers. Once sufficiently ponerized, they may be able to move up the ladder a bit, if they can fit in with the sharks, they may make it to executive level. The common workers, however, are used as disposable commodities.
I can't overstate how insidious and damaging this ponerization process is. My experience is that most people in the health care field, especially those drawn to patient care, are at heart extremely compassionate and caring.
My experience is also that years in patient care in a corporate environment burns out and often ponerizes all but the most saintly of caregivers.
Fourth - my take on the corporate response is that it simply shunts ALL responsibility away from the corporate practices, rules, and culture that produced such compassionless workers and took "immediate disciplinary action" on the lower level workers.
I don't deny the workers are responsible for their actions, but even more so, the executives are responsible for creating unnatural, ponerized humans that could behave like that.
I have seen this shifting of responsibility from the decision-makers onto the common workers again, and again, and again.
This is a part of the evil we face.