Review of Investigation into Death of Boston's Laura Levis

Last fall we shared the story of Boston's Laura Levis, who died in September 2016 after being locked out of an ER during an asthma attack.  We initially critiqued the story, including the hospital's apology, in this article, then provided an update a few weeks later in this blog post.  That last update stated that the hospital hired an outside law firm to review the case top to bottom and ask several important questions, including why the hospital was slow to apologize to Ms. Levis' family.  Well, the 85 page report detailing the investigation of Laura's death by the law firm was recently released.  

Laura's widower, Peter DeMarco, told the Boston Globe he was "disappointed" in the report and felt the document undermined the apology he received from the hospital, but he also added the following: "My feelings about this report honestly won’t matter if the lessons learned from it do indeed help save lives in the future.”

There is a lot of learning in this report...it provides a lot of important lessons for healthcare organizations to learn how to better handle and communicate about adverse events. And the fact the report was written by a law firm should increase its credibility.  I strongly encourage Sorry Works! followers to read the report and share with colleagues. Jeffrey Catalano, a Boston personal injury attorney who is involved in state's disclosure movement, told the Boston Globe that the report is "commendable."  I agree.  

Here is our critique and comments, and hopefully lots of learning in these remarks too: 

- I can understand how Mr. DeMarco is disappointed in the report and feels like it undercut the apology he received from the hospital.  In my opinion, the law firm tried to validate some of the hospital's conduct, and it came off as tone deaf.  First, saying that the hospital system "did many things right" doesn't ring true after they gave an apology to Mr. DeMarco.  Second, the report read, "...we found no evidence of an intentional effort to mislead or withhold information" from Mr. DeMarco or the family.  Yet, in this very same report the law firm (starting on pages 17, 18, 19, 20) states that an investigation and call to insurer carrier about Ms. Levis being locked out of the ER commenced almost immediately but nobody told Mr. DeMarco about this investigation, even after Mr. DeMarco wrote a glowing letter to the hospital thanking them for the care provided to his wife.  In fact, Mr. DeMarco posted this letter on Facebook and it went viral, eventually landing in the New York Times and NBC News -- still nobody shared with Mr. DeMarco that an investigation was underway.  Hospital leadership was well aware of Mr. DeMarco's positive feelings about what they did for his wife, while, at the same time the hospital was actively investigating what they did to his wife.  On page 17, the law firm excused the hospital's behavior by saying, "they believed that Mr. DeMarco knew the details about Ms. Levis' attempted entry (into the ED) and wrote the letter anyway."  No way.  You have the link for the report above...judge for yourself.  I believe a more fair read would say this was a classic example of a hospital knowing there was a problem and investigating the problem without telling the family or being pro-active but the whole thing blew apart.  Take a look at Exhibit C, page 10 in the report for some frank admissions from leadership.  Also, look at page 39, fourth paragraph. This stuff happens all too often in medical malpractice, and this case blew apart in a very, very public fashion.  

- To their credit, the law firm states that the hospital needs to develop a protocol/program to make sure families are notified about investigations/reviews and also to review if disclosure and apology has happened with the family in a timely fashion.  This sorta stuff didn't happen 20 years ago....I call this progress.  Look at pages 7, 32, 40, and 41 -- and remember these recommendations were made by lawyers!  Share these passages with the skeptics!

- Also, the law firm acknowledged the PR damage to the hospital, saying on page 28 that Mr. DeMarco's November 2018 article in the Boston Globe was the paper's most read article that year.  On page 43 they wrote, "The reputational harm to CHA extended beyond bad publicity.  It decreased morale, promoted divisiveness, and led to a questioning of effectiveness within the organization.  All of this might have been avoided if CHA had given timely notice to Mr. DeMarco that Ms. Levis' case was under review."  So often lawyers miss the PR perspective of cases....bravo for this section of the report.  

- The law firm stated they interviewed 25 people (page 3), but it wasn't clear if they interviewed Mr. DeMarco and other family members.  Later on page 38 the law firm said they interviewed Mr. DeMarco.  Please understand, no review is complete without talking to the family, and the fact those interviews happened need to be spelled out clearly in the beginning of any report.    

-  In our earlier report on this story, Mr. DeMarco said his lawsuit was eventually dropped because of the Massachusetts $100K cap on "public hospitals" made the case economically unfeasible. Mr. DeMarco had wished to use money from the settlement to do good works in his wife's memory.  Yet, on page 27 of the report the law firm reported the hospital system did offer $100K to Mr. DeMarco, which he rejected.  The recent Boston Globe story expressed hope that the hospital and Mr. DeMarco may work together in the future.  Mr. DeMarco was featured this week on NBC discussing his wife and asthma, and he is also working on patient safety and malpractice reform legislation in Massachusetts.  Mr. DeMarco is an excellent communicator and advocate, and he is becoming a force. I would hope that the hospital and Mr. DeMarco could work together, and financial support from the hospital even exceeding the $100K cap could help fund joint efforts.  Both sides need to search their hearts....

- Lastly, this report is a testament to the progress we have made in the disclosure movement.  This type of report -- complete with recommendations for improvements -- would have never been released to the public 10 to 20 years ago, let alone the family in private.  Sure, the report is not perfect, but the learning that will come from the report is potentially enormous.  Again, here is the report.   Read and share with colleagues...it can help a lot of patients, families, and doctors and nurses.  

Have a great holiday weekend.

Sincerely,

- Doug

Doug Wojcieszak, President
Sorry Works!
618-559-8168 (direct dial)
doug@sorryworks.net (direct e-mail)