A report expected this spring from the law firm investigating a 2016 death outside CHA Somerville Hospital will be made public, Cambridge Health Alliance officials said Tuesday at a City Council committee hearing.
Board of trustees chairman Joshua Posner promised a public airing of the report during a City Council discussion of “lessons learned” from the death of Laura Levis and what the Alliance is doing to prevent a similar occurrence. The trustees hired the law firm of Foley Hoag in November to look into “systemic issues as well as communication failures with families,” Posner said. The board appointed a special committee to oversee the investigation.
Levis, a 34-year-old Somerville woman, couldn’t find the entrance to the Somerville Hospital emergency room while suffering a severe asthma attack Sept. 16, 2016, and she died after going unseen by a nurse peering briefly outside from a door.
Levis’ husband, Peter DeMarco, also asked support for two bills in the Legislature: one requiring the state Department of Public Health to write regulations setting standards for emergency room access statewide, called “Laura’s law”; and the other removing a $100,000 cap on awards against public and nonprofit hospitals for malpractice that results in serious injury and death.
Outgoing CHA chief executive Patrick Wardell indicated at the hearing that the Alliance would support the bills, but health care system spokesman David Cecere said later that Wardell misheard the question.
The health care system does support the bill establishing statewide standards for emergency room access, but for the bill removing the malpractice award cap, “our board and leadership are still evaluating the legislation and have not made any decisions,” Cecere said.
DeMarco also asked councillors at the Human Services & Veterans Committee hearing to support the bills, and an item on Monday’s City Council agenda sponsored by them seeks council support. The Alliance is a “public hospital” and the City of Cambridge provides $7 million a year to operate the city’s Public Health Department, plus pension subsidies.
Explanations and apologies
Levis’ death drew little attention when Cambridge Day published an article noting it Jan. 2, 2018, based on a Department of Public Health investigation report with no names included. But public outrage erupted after DeMarco, a reporter, wrote a detailed and moving article in the Boston Globe magazine Nov. 4 disclosing that CHA never told him and family members what had happened to his wife before she was taken into the emergency room by an ambulance crew,
Alliance officials apologized in a statement the night DeMarco appeared on NBC Nightly News; top officials met later with DeMarco at the Globe office to apologize again and answer his questions for the first time.
On Tuesday, each of the four top officers at the Council hearing – Posner, Wardell, chief nursing officer Lynette Alberti and chief medical officer Assaad Sayah – apologized to DeMarco before making presentations.
DeMarco, who also testified at the hearing, said he thinks the health care system truly wants to change its practices. “CHA withheld the truth from our family for more than two years,” he said. Now, he said, it is “trying to do a 180-degree turn.” He thanked Alliance officials for their efforts.
In Alliance’s defense
The health care contingent cited some facts in their defense. Alberti said “vital information” from Levis’ 911 call to police “was never shared with the Somerville Hospital emergency department.” She referred to reports that an ER nurse wasn’t told that Levis was having a severe asthma attack. Emergency room staff was also told that a police officer had been “sent to the site,” Alberti said.
Sayah said there was a shift change as DeMarco arrived at the hospital at 7 a.m. and the new team caring for Levis didn’t know what had happened. “It wasn’t necessary for them to know” to treat Levis as they tried to save her life, he said. She was transferred to Cambridge Hospital – Somerville Hospital has no inpatient beds – and died seven days later.
“The clinical care to Laura was excellent,” Sayah said.
Yet managers did not tell DeMarco, family members and the clinicians caring for Levis about a subsequent analysis by the hospital’s quality and safety department examining the events before Levis got into the emergency room, Sayah said. “That was a huge error,” he said.
Physical upgrades …
The health care system officials described many changes in response to the incident, including improvements to lighting and signs at all three of its hospitals – Somerville, Cambridge and Everett – and upgrades such as installing sensors at Somerville entrances that ring a bell when someone comes in and establishing a central monitoring station that allows an employee to watch entrances at all clinics and hospitals and keep track of 911 calls to and from those facilities.
The system also obtained a new address for the hospital on Somerville’s Tower Street to eliminate confusion between the hospital and the entrance to outpatient clinics on the other side of the building, on Highland Avenue. “We discovered that if you ask Uber to drive you to Somerville Hospital, they will drive you to Highland Avenue,” Sayah said. After Levis called 911, police and hospital workers weren’t sure whether she was calling from outside the emergency room or from the Highland Avenue entrance.
… and policy changes
CHA also developed policies “to define who is responsible” for telling family members about what happened to their relative, including events “outside the hospital,” Sayah said. “We added steps to remind people, is an apology needed?”
Many changes described at the council hearing were made soon after Levis died and the Alliance submitted its “plan of correction” to the Department of Public Health. After DeMarco’s article was published, “we re-reviewed the case to see what further opportunities exist for improvement while also ensuring we reinforce training, guidelines and protocols,” Cecere said.
Asked for examples of how the changes had helped patients, Sayah said he couldn’t provide numbers but recounted how a laboratory technician leaving Everett Hospital at the end of her workday noticed “a young man by the entrance semi-conscious,” with another person standing beside him. In response to her alert, hospital workers found four teenagers who had overdosed on narcotics outside the hospital, Sayah said. That incident occurred in November, Cecere said.
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