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November 16, 2018

Getting closure: Health system apologizes, more than 2 years after patient who couldn't access the ED died

Daily Briefing

    On Tuesday, leaders at Cambridge Health Alliance sat down with the husband of a woman who died after collapsing outside a locked ED door in 2016, offering their apologies and acknowledging "multiple failures," the Boston Globe reports.

    During the two-hour meeting, Patrick Wardell, CEO of Cambridge Health Alliance; Assaad Sayah, chief medical officer at Cambridge Health Alliance; Lynette Alberti, chef nursing officer at Cambridge Health Alliance; and other officials answered Peter DeMarco's questions about his wife's death.

    Wardell said, "I'm very sorry for what happened to your wife. ... I can understand the horrible pain that this has inflicted upon you." He added, "I take personal responsibility for this."

    What happened to Laura Levis

    In 2016, Laura Levis arrived at Cambridge Health Alliance's Somerville Hospital seeking care for an asthma attack. In a Boston Globe Magazine article published earlier this month, DeMarco explained that his wife commonly experienced asthma attacks. The most severe ones built up slowly over time and required short trips to the ED, where she typically was treated with "prednisone, a nebulizer treatment, or both."

    But on Sept. 16, 2016, Levis never made it inside Somerville's ED, where she went around 4 a.m. seeking treatment.

    Police reports and hospital surveillance videos acquired by DeMarco after Levis' death show that Levis approached one of the hospital's two ED entrances, but when she approached the sliding glass door did not open.

    "Surprised, she put both hands on the door and moved her face toward it to peer through the glass. It still did not open. She turned again toward the plate-glass windows, looking for someone to let her in. But the corridor, and the waiting room, were empty," DeMarco wrote.

    DeMarco continued, "Finding that door locked, [Levis] almost certainly panicked. Maybe that is why she didn't comprehend the instructions posted on that sliding door, in simple white lettering, explaining that it was for ambulance access only. ... To enter the [ED], the instructions read, patients needed to use the main hospital entrance—the door to the far left. The door she had not chosen."

    According to DeMarco, Levis eventually "turn[ed] and beg[an] walking toward the main entrance, about 100 feet away." But Levis did not make it there. "[W]hen Laura reached [a] waiting bench, just 29 feet from the main entrance of the hospital, she sat down. The attack had become so intense, she could not walk those extra 29 feet."

    She called 911 and told a regional 911 operator, "I'm at Somerville Hospital. I'm having an asthma attack. I'm dying." The operator could screen calls but could not send help directly to Levis. The operator connected Levis with the local police department in Somerville, but at that point Levis could barely speak. The regional operator repeated what Levis had told her: "She's outside of the Somerville Hospital. She's having an asthma attack. She can't get into the hospital there."

    Police notified the hospital, but DeMarco writes that no one passed on Levis' exact location. Without that information, it took hospital staff about 15 minutes to locate Levis.

    According to DeMarco's account, a nurse took "one step outside … going no further than an arm's reach from" the entrance door, and "[i]n the predawn darkness, [the nurse] crane[d] her neck a bit to see, but she [didn't] spot Laura on the bench."

    By the time they found her, it was "too late," DeMarco writes.

    Levis spent seven days in the ICU before the doctor said Levis was unlikely to recover. DeMarco at the time penned an emotional letter thanking the hospital staff for their care and compassion during his wife's time in the ICU. But in the Boston Globe magazine he wrote he'd been unaware of the events that led to Levis' death. "During all that time, no one mentioned anything to me about Laura making it to the doorstep of Somerville Hospital's emergency room," he wrote.

    It wasn't until five weeks later, when Levis' father, William Levis, obtained two police reports, that they learned the truth. Levis, a former officer with the U.S. Public Health Service, called DeMarco and told him, "I have the most terrible thing to tell you. They killed Laura."

    DeMarco filed a complaint with the Massachusetts Department of Public Health over his wife's death. The department investigated Levis' death, "eventually citing the hospital for failing to provide a safe environment and for 'poor quality of pre-hospital care,'" DeMarco writes.

    Hospital leaders acknowledge shortcomings

    More than two years after the incident, Cambridge Health Alliance leaders met with DeMarco to discuss the situation in detail.

    According to the Globe, officials from Cambridge Health Alliance had previously declined to comment on the incident.

    During the meeting, Assaad Sayah, chief medical officer at Cambridge Health Alliance, told DeMarco the health system's investigation into Levis' death revealed many problems at the hospital and presented DeMarco a list of steps they'd taken to correct them. For instance, Sayah said the hospital has improved its lightning, signage, training, and video surveillance.

    Sayah said, "It's hard to continue saying we failed, but we did fail."

    While DeMarco said he was disappointed by some of the answers he received, he was grateful to finally hear from the health system's executives. "They offered me accountability today by admitting their mistakes, by finally doing the right thing," he said (Dayal McCluskey, Boston Globe, 11/13; DeMarco, Boston Globe, 11/3).

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