Checks and balances must exist, especially in the medical field, where wrong action or failure to act can dismantle, disable, and end human lives. Within Colorado, there exists a statewide hospital system that is devoid of this concept, with deadly consequences.
Some time ago, a law was passed in Colorado that made University of Colorado Health hospitals and staff basically immune to any kind of punitive litigation for malpractice. They can be sued, but the cap is so low that lawyers don’t see the point in pursuing malpractice suits, as they say it makes no sense financially. Therefore, even if one is disabled, injured or killed by a medical error, they have no recourse.
Countless have been harmed at UC Health, just as people are harmed at hospitals all across the world. The risk of harm is a risk patients take when they undergo surgical procedure and it is a known risk that is assumed by all healthcare professionals as part of their oath, their job and their duty.
However, litigation exists within the medical system to keep healthcare professionals honest and ethical. It provides a sort of check and balance to the natural human condition as most people, especially when under duress, act out of ego or fear or anything other than the highest good. This includes healthcare providers.
Therefore, a healthy fear of litigation must exist to help doctors, nurses, and other health care providers give patients a quality of care that is deemed safe, and in alignment with current, evidence-based best practice. When these standards of care are not met, patients suffer. Harm is done. Therefore, all patients must have a right to defend themselves if this happens, just as all people have a right to press criminal charges against someone who committed assault or homicide, for example.
At UC Health, the doctors and nurses know that they are basically immune from litigation - meaning if they harm a patient, they personally will not lose their license nor will they face fines or jail time. In addition to this, they are defended in malpractice suits by the Attorney General, the prosecutor for the State of Colorado.
How did all this information get uncovered? Why was it covered in the first place, and why should we care?
Samuel Simon Pérez-Wright, a 33 year old vital, healthy, young human with only one underlying non life-threatening chronic, stable health condition, went to the University of Colorado main campus in Aurora at least eight times over the course of six weeks with the same complaint, severe abdominal pain. Each time he was diagnosed with a bowel obstruction of unknown origin, told not to eat for a while, sent home with no answers and told to come back if it gets worse. He was never offered a solution, even though a bowel obstruction is the precursor to a bowel perforation, which is a medical surgical emergency and kills most people.
One week, Sam went to UC Health Anschutz three times in one week with the same complaint: worsening, debilitating abdominal pain that caused him to be doubled over and constantly screaming in pain, requiring high doses of the strongest medications and still never tolerable. They dismissed his complaints as the same as before even though he was doubled over and screaming and they didn't even do the standard of care, which is a CT scan to assess for bowel perforation, when he arrived at their ER for the final time.
Sam was in their ER for the last time for a day before the the staff at UC Health were forced to perform an emergency trauma surgery because they missed the bowel perforation initally. They didn't do a CT scan for at least 18 hours from the time he presented. After the CT scan showed a perforated bowel, which is an absolute medical emergency, at least 6 hours went by before they finally performed the life saving operation he needed.
During these hours Sam was in severe pain. His family was forced to be at home because of visitor restrictions. But Sam took it into his own hands and took a video from his hospital room which Whitt found after he died. This video shows staff performing an unwanted and unauthorized procedure on him. Sam is screaming and crying in pain and asking them why they weren't helping him. At the time stamp of this video, Sam's bowels had already exploded inside him and his vital internal organs were surrounded by fecal content and bacteria. His intestines were dying and he was bleeding internally. The video was time stamped hours before they even told his wife anything was wrong.
By the time Sam was on the operating table, he was nearly dead. He was bleeding out. The doctors had him in surgery for hours, they removed a large portion of his bowel that had died, and left him with a 10 inch incision and an ileostomy from an unnecessary trauma surgery. They told Whitt, his wife, that he likely would not survive the surgery. The next day, he was walking in the hallways and laughing so loudly the entire floor could hear him.
Sam did the impossible. He survived the surgery that hardly anyone survives and was told that he may be able to even go home within a few weeks. In the days after the surgery, a progression of negligent, harmful, terrible care ensued, the worst of which was an error with oxygen administration that caused Sam's brain to be deprived of oxygen for long enough that his brain herniated through the back of his skull.
His partner was then forced to turn off the machines, after the doctors gave the news that somehow Sam’s brain had become too damaged for him to even take a breath on his own.
Whitt is an expert ICU and cardiovascular nurse with over a decade of bedside experience, who knew the whole time that everything was going wrong. Multiple complaints were filed, and they were stonewalled at every turn. Whitney knew they made a mistake that caused Sam to go from a walking miracle to brain dead in a few weeks at their hospital.
The truth didn't come out until the autopsy report was finalized. The doctors at UC Health had told Whitt that Sam’s death was ultimately caused by complications from his preexisting, chronic, stable condition which was worsened by the unnecessary trauma surgery. They never admitted to herniating his brain.
They took no ownership of the fact that they didn’t treat his bowel obstructions seriously or offer the standard of care solution, an exploratory surgery under non emergent conditions. They took no ownership of the fact that they missed the perforation for hours while Sam was suffering in their hospital. And they took no ownership of the critical nursing error that caused Sam's brain to be no longer functional and ended his life.
Not until the autopsy report came out did they discover that not only did UC health deprive Sam of oxygen causing anoxic brain injury, but they deprived him of oxygen so severely that his brain actually exploded through the base of his skull, otherwise known as herniation.
You really have to mean it to herniate a brain. Common causes of this are closed head injuries, brain tumors, aneurisms, and massive strokes. Bowel obstructions, however, do not cause the brain to herniate.
To make matters even more interesting, UC health failed to report Sam’s death to the coroner as required by Colorado and also CMS. They instead did their own internal autopsy without notifying Whitt that this was the case. Whitt knew as a nurse that this type of death should have been automatically reported to the state medical examiner, and never thought the doctors at UC health would hijack his body to do their own biased assessment that still told the terrible truth: they herniated his brain.
Whitt, upon receiving the autopsy report, called the Attorney General of Colorado with this information. Their representative advised that Whitt say no more to them about the case, because the Attorney General defends UC Health and their doctors in any lawsuit brought against them. Amazed at the corruption that was protecting UC Health, Whitt then brought criminal charges against them because this was now proven to be beyond malpractice. This was beyond negligence. This was homicide.
As healthcare professionals we have a duty to act. Not only do we have a duty to do no harm but we have a duty to act when the lack of action will cause more harm than good. The staff at UC Health failed Sam and the system failed Sam and it has failed and killed many other people. Something must be done to change this.
Most people in Colorado have no idea that if they happen to get into an accident and end up at UC Health and an error is made that changes their life.. or ends their life, they have no recourse. No justice. No way to defend themselves.
UC health hides their corruption behind a false banner of being the state’s teaching hospital and striving to provide care for the residents, but experience shows this is false. The culture at UC Health is reflected directly by the doctors and nurses gross incompetence, absence of compassion, and complete inability to provide even a standard safe care environment for their patients. They hide their corruption behind a banner of teaching, doing good and providing excellent care, but they need to be completely deconstructed, unprotected, and held accountable for this harm they are doing to people.
Whitt and Sam will do everything in their power to ensure justice is served for Sam, and this system can no longer destroy lives.