My son, Mark David Turnage, Jr., died at Valley Medical Center (VMC), in Renton, Washington due to a horrendous amount of hospital preventable adverse events – ERRORS that could have been prevented and Mark would be alive today. Mark was 30 years old when he passed away and had so much life left to live. We miss Mark so very much – life will never be the same without him.
I am horrified at the number of hospital errors that could have been prevented by the VMC doctors and staff. To summarize these in a couple of pages wouldn’t begin to detail the chain reaction of the one preventable adverse event that caused a total healthcare system collapse at VMC. Mark was not safe; there was no quality of care. These errors are detailed further on Mark’s blog www.valleymed.blogspot.com
The journey to Mark’s death began on November 9. Mark was taken to the VMC Emergency Room (ER) this evening because he was having “pains in his chest – the upper right.” Through lab work VMC diagnosed Mark as having pancreatitis; VMC admitted Mark at 2:30 am right from the ER. Of note is we found out the pancreatitis was caused by gallstones which were documented on an ultrasound report – none of the VMC doctors reviewed this report, I had to show it to them.
Mark knew his medications, doses and was coherent in the ER (I was with him); the ER nurse didn’t write the medications down correctly. I also reviewed these medications with the 3rd floor nurse, as I made her put them in the computer system because they were still listed wrong. I asked this nurse to contact Swedish (where Mark’s doctors were located) to confirm the proper doses. Days later the VMC doctors still don’t know the correct medications and doses Mark was taking prior to his hospitalization. Mark’s medical condition plummeted from abrupt medication withdrawal. VMC misdiagnoses medication withdrawal and tells us Mark is septic from the pancreatitis.
Mark was then given medications (Opiods, Opiates, and Benzodiazepines) known to cause toxic interactions with the MAO inhibitors Mark had been taking for years. These deadly combinations of drugs caused Mark to stop breathing and his blood pressure dropped. Mark was intubated on November 12 at 1:30 am and within days the hospital acquired bacteria (MRSA, Enterobacter, Burkholderia and later Pseudomonas) begin to grow in Mark’s lungs – cross-contamination from hospital procedures and equipment spread the bacteria into Mark’s gastrointestinal track. I located in Mark’s medical records that another patient acquired the same bacteria after my son did – a whistleblower also came forward because instruments were not being sterilized properly (and the records were falsified).
VMC’s response – Mark had these bacteria in his lungs and intestines 13 years previous.
Because of all the errors we tried everything in our power to have Mark transferred to Swedish where all his doctors were located including pay out of pocket for the ambulance transfer. We discussed our concerns with the doctors about the errors and that we lost all confidence in the VMC doctor’s ability to care for Mark. We were told Swedish rejected the transfer. There is no record of whom Dr. Mary J Vancleave (who is no longer employed by SouthLake Clinic) contacted at Swedish; Swedish has no record of ever being contacted.
While the VMC doctors were given the facts and data to prescribe the correct antibiotics needed to fight the bacteria VMC gave to Mark the VMC doctors continually ignored recommendations presented to them (from the University of Washington [UW], from their own lab, one doctor (Dr. Michael Hori) is said to be “in charge of prescribing all drugs for Mark.” Dr. Michael Hori actually stopped all antibiotics when Pseudomonas was discovered – I questioned this and the antibiotics were started again.
Why the VMC pharmacy did not perform their job in questioning and rejecting these medication decisions made by VMC doctors will always be a very big concern to me. The administration of antibiotics was literally a “shot gun” approach – other drugs prescribed should have never been given to Mark because of the gallstones/pancreatitis, liver metabolism and warnings because of the bacterial infections. Because there is no check and balance system at VMC between their doctors and the pharmacy patients are at risk; VMC actually told me (based on medication questions in my letter) that they really have no idea which drugs were actually given to Mark – but they are sure he wasn’t charged for all of them. I counted every entry of a medication VMC billed us for – 2599 entries costing $293,790.98.
At one point the VMC doctors (and one was a neurologist) told us my son was brain dead and to put Mark on “comfort care” because there was nothing else they could do for him. Within hours of this “comfort care” Mark woke and up and was communicating with us.
Four days after this “comfort care” event I had a conversation with Dr. William Park. He was concerned about the pseudomonas in Mark’s lung – and says the pancreatitis is in control (it was not). I told Dr. William Park that Mark will fight the bacteria. The very next day (under Dr. William Park’s command) Mark received a drug called Dexamethasone (December 26 to January 7) which is contraindicated with the bacterial infections VMC gave Mark. Dexamethasone alone caused the VMC bacteria to run rampant through Mark’s body (Mark’s white blood cell count skyrocketed). There was no informed consent.
5 VMC Gastrointestinal (GI) doctors were supposed to be monitoring Mark for pancreatitis (Doctors Christopher DiRe,Eric Yap, Daniel O’Neill [who is no longer employed by SouthLake Clinic], William Pearce, Duane Carlson [who is no longer employed by SouthLake Clinic] and Frank Thomas). Mark had documented gallstones (which none of them read the report) and was given medications contraindicated with pancreatitis/gallstones. None of these doctors followed through and verified the records or medications given. These same GI doctors never treated the pancreas pseudocyst that developed. While Dr. Daniel O’Neill recommended a transfer and consult with Virginia Mason GI for a stent – his orders were ignored. None of these GI doctors saw Mark from December 20 through December 29 and they should have been monitoring their patient. There was minimal pancreatic tissue noted at Mark’s autopsy.
VMC doctors (Stefanie Nunez, Suzanne Krell, William Park, Richard Wall, Michael Hori, and the Pharmacy) were given the facts and data of Mark’s 2C9 inhibitor study precautions (a genetic study of how your liver metabolizes medications) but continually ignore this critical information and give Mark medications known to cause elevated liver enzymes (and damage/failure). VMC pharmacy and Gastrointestinal (GI) staff did not perform their job in questioning these medication decisions. Because of these medication decision errors, Mark’s liver began to fail.
There are so many other errors that happened during Mark’s hospitalization at VMC. Even Dr. Wynne Chen’s “Discharge Summary” of Mark’s death states many inaccuracies. If you are going in the hospital, do your research and if you have a chance go to Mark’s blog and read what can happen to you. I am hoping in sharing Mark’s story that a life will be saved.
The root cause in all of this at Valley Medical: There was no check and balance system –policies/procedures were not followed – no working quality system – no working infection control system – no leader/leadership to direct Mark’s health care planning (project manager) – no working state regulatory system to hold Valley Medical and their “consultants” responsible.
Karie Turnage-Fugate (Mark’s mom)
karieturn@comcast.net
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