The Cambridge Health Alliance made physical changes at Somerville Hospital after woman died trying to finding the emergency room in 2016. (Photo: Marc Levy)

Cambridge Health Alliance has hired an outside consultant to examine how doctors, nurses and officials failed to tell the husband and family of Laura Levis that the young Somerville woman could not get into the Somerville Hospital emergency room when she was suffering a severe asthma attack.

Levis collapsed on a bench near the hospital entrance Sept. 16, 2016, after futilely trying a locked door. Somerville emergency dispatchers had notified a nurse in the emergency room that a woman seeking treatment was outside; the nurse briefly looked out and failed to see her. By the time an ambulance arrived, Levis was in cardiac arrest; she died seven days later at Cambridge Hospital.

Her husband, Peter DeMarco, was never told what happened. He found out from a police report, he said in a moving article in the Boston Globe magazine Nov. 4. The story has put CHA under scrutiny, and the health system apologized for the first time Nov. 7, followed by top officials meeting Tuesday with DeMarco to apologize personally and answer questions.

Peter DeMarco and Laura Levis in an undated photo.

The disclosure that CHA is using a consultant to look into what went wrong came in an email Tuesday from chief executive Patrick Wardell and board of trustees chairman Joshua Posner to City Manager Louis A. DePasquale. The message described the consultant as an “independent reviewer.” DePasquale forwarded the message to city councillors.

The Alliance operates Cambridge, Somerville and Everett Hospitals and has clinics in Cambridge, Somerville, Malden, Medford, Revere and Everett. Although it’s managed independently, it is part of Cambridge city government. The city contributes $7 million a year in return for CHA’s running the Public Health Department.

As city manager, DePasquale appoints CHA trustees. He also happens to be a trustee himself and heads the board’s finance committee.

Communications breakdown

The email from Wardell and Posner included details on the communications breakdown that are the first public disclosure of how DeMarco and Levis’ other family members were left in ignorance.

Doctors and nurses caring for Levis at Cambridge Hospital – where she was transferred after finally being carried into the Somerville Hospital ER – were not told that “pre-admission issues that involved Somerville were being reviewed,”  and they didn’t get updates, Wardell and Posner wrote.

The system didn’t assign “a responsible party to share information with Laura’s family as it emerged,” the message said. When managers and others inside CHA discussed “‘informing the patient family, they considered only the clinical issues, not the pre-admit issues,” it said.

The email said CHA “missed opportunities to reach out” to the family before a lawyer for DeMarco contacted the Alliance; after that officials “defaulted to the standard process around communications after being contacted by legal counsel.”

DeMarco did not file a lawsuit after the law firm told him that public hospitals such as CHA were protected by a $100,000 legal cap on malpractice claims and the cost of suing could exceed that. He told CHA officials that he didn’t intend to take legal action, but they refused to answer his questions, saying the Alliance was still within a three-year statute of limitations for claims.

Expected changes

Cambridge Day published a story about the case Jan. 2 but could not obtain the name of the patient who died; a spokesman refused to answer specific questions at that time.

Wardell and Posner gave a general description of changes that CHA expects to make as a result of its reexamination of Levis’ death. It includes “updating our communications and apology policies” and establishing “checks and balances to [ensure] that information is shared in a timely fashion.”

CHA made physical changes at Somerville Hospital, including an ER entrance open 24 hours a day, new signs and improved lighting, the email said. Those changes have been previously reported.

The email also disclosed that the health care system “indicated that we will work collaboratively with the Somerville Police Department (and others, as needed) to address broader issues.” The message didn’t identify those issues. DeMarco’s article said a Somerville police detective who helped EMTs find Levis outside the ER was angered when someone inside the emergency room seemed annoyed at the detective’s effort to get help for Levis from hospital employees.