Confusing hospital configuration, 911 system factored in 2016 death of woman seeking ER
Cambridge Health Alliance, under a harsh spotlight because a young woman died after she couldn’t find the entrance to its Somerville Hospital emergency room, is trying to eliminate “a failure of our communications systems” that kept the woman’s husband in the dark about what happened, spokesman David Cecere said Tuesday.
The statement came after chief executive Patrick Wardell and other top CHA officials met with Peter DeMarco of Somerville at The Boston Globe offices Tuesday to apologize personally and answer DeMarco’s questions about the death of his wife, Laura Levis, for the first time. DeMarco wrote a moving article in the Globe magazine Nov. 4 about how his wife collapsed in September 2016 just feet from the main entrance to the hospital with a life-threatening asthma attack, unseen by a nurse who peered briefly out the door.
A confusing hospital layout and troubles connecting directly to emergency police services using mobile phones are also being looked at in the aftermath.
Three dozen questions
Speaking about the Tuesday meeting, DeMarco said he recognized that the Alliance “took a big step by meeting with me today.” The CHA officials – Wardell, chief nursing officer Lynette Alberti, chief medical officer Assaad Sayah and Cecere – “at least tried to answer” the three dozen questions he asked, DeMarco said.
“Some they answered well and some the answer left me wondering what the true answer was,” he said. “At least they owned their mistakes, so that was really necessary and I thank them for trying.”
“It was very hard to hear about all the mistakes that were made and they owned up to that led to Laura’s death,” DeMarco said.
Cecere said: “We were grateful for the opportunity to meet with Mr. DeMarco, apologize for our actions, express sorrow for his loss and answer his questions.”
Begun in September 2016
Until now, no one at the Alliance had acknowledged the story of how Levis had tried one door to the emergency room early Sept. 16, 2016, and found it locked, then lost consciousness on a bench near the main entrance while Somerville police told the emergency room nurse that a woman outside couldn’t find the entrance. EMTs eventually came to the hospital and found Levis, but her heart had stopped by then. She was revived but died at Cambridge Hospital seven days later.
DeMarco found out what happened from a Somerville police report. Cambridge Day reported the case in an article published Jan. 2 but could not learn the patient’s name. Cecere refused at that time to answer specific questions.
The health care system apologized for the first time on Nov. 7 after DeMarco was interviewed on NBC Nightly News. Cecere said Tuesday that it was due to a communications failure that no one had told DeMarco the full story of his wife’s death “once we had more information about the factors that led to a delay in his wife’s admittance to the Emergency Department.”
“We are making every effort to improve those systems to [ensure] future compliance with our own high standards around patient disclosure,” he said.
Assumed he’d been told
According to a state Department of Public Health inspection report, the hospital analyzed the event five days after it happened and a staff meeting was held a month later to discuss the case. The state cited the hospital for violations several months later in a report. The Alliance agreed to pay a fine of $90,000 to settle allegations that it violated a federal law requiring hospitals to assess and treat anyone who comes to the emergency room. The Alliance had initially claimed it didn’t violate the law because Levis was not in the emergency room itself.
Wardell told DeMarco he had assumed DeMarco had been told the full story, according to a report published in the Globe late Tuesday.
DeMarco said he appreciates that the health care system officials have offered to meet again, and that he is considering his next step.
Problems with the 911 system also contributed to the delay in getting help for Levis. She had called the emergency number from her cellphone and was first connected to a regional center because many cellphones are not capable of connecting directly to a local emergency dispatcher. Then the Somerville police couldn’t get an accurate location because of limitations of the GPS system, as DeMarco reported in his article.
The layout of Somerville Hospital also caused confusion; an entrance on one side leads to primary care and other doctors’ offices, while the ER, the main entrance, and other departments are on the other side, up a steep hill. Police weren’t sure where Levis was when she said she was trying to get into the emergency room.
The state is trying to help local emergency dispatchers move to a system that allows cellphone callers to connect directly to local centers and offers more accurate location information.
Improving the system
City councillor Jan Devereux said in a post on her website that Cambridge residents can sign up for Smart 911, a free service that sends more accurate location information for emergency calls from Apple and Android cellphones. Residents can also record personal and medical information that will go automatically to Cambridge EMS dispatchers, she said.
The city also offers free signup for 10 years to RapidSOS Haven, an app that also provides more accurate location information for cellphone calls, Devereux said in her website post, but she amended that Wednesday to say the service is no longer free “due to advances in Apple and Android services.”
Spokesmen for the Cambridge Police Department and city manager did not respond Tuesday when asked the status of other new 911 technology being offered by the state government.