Family’s grief, guilt turn to anger
Nurse reveals what really happened at hospital the day elderly matriarch died
“It was my job to protect her,” Chapa says of her 87-year-old mother.
The package came in January: An anonymous letter and a stack of government records, stuffed in a yellow envelope with no return address and mailed to her late mother’s home in Damon.
Cris Chapa ripped it open and began to cry.
She thought of the day, March 12, 2015, when medical staff at Kindred Hospital Sugar Land sat her down in a waiting room. They’d said there was nothing anyone could have done. Led her to believe her 87-year-old mother’s death had been the inevitable result of her bout with pneumonia.
The stranger’s letter told a different story:
Her mother hadn’t died peacefully, it said. Instead, a doctor had attempted a procedure without Chapa’s knowledge or legal consent, and it had gone badly. Blood poured from a tube in her mother’s neck. Soaked her hospital gown. Caused her heart to stop.
Why hadn’t anyone told her what happened? Why didn’t anyone tell her three months later, when the state sent someone to investigate? Why didn’t anyone tell her a few weeks after that, when the federal government cited the hospital for violating her mother’s rights?
For nearly two years, Chapa and her family had been kept in the dark. Until now.
She didn’t know it then, but the stranger who’d written the letter had mailed duplicates to two of her siblings. Chapa’s hands shook as she studied the documents, looking for clues to who’d sent them, but she found only an email address.
That night, she logged on to her computer and typed a message: “Can you call me?”
Linda Patton read the email twice, unsure how to respond.
She’d been hesitant to contact Chapa in the first place, even anonymously. She’d already lost so much.
This wasn’t the life she’d hoped for when she accepted a job as a nurse practitioner at Kindred Hospital Sugar Land in September 2014. She knew it had been a risk leaving Houston Methodist Hospital for a less-prestigious facility, but Kindred had offered her a more senior position and an opportunity to mentor young nurses, which was her passion.
Patton noticed problems right away, she said. On daily rounds, she’d quiz nursing staff on what medications patients were taking. What side effects they should be looking for. Basic stuff. Routinely, though, nurses didn’t know the answers, and some seemed agitated by her attempts to educate them.
“That just kind of shocked me,” Patton said.
She hadn’t realized her new hospital had a history of mistakes. In the three years leading up to her first day at Kindred, the federal Centers for Medicare and Medicaid Services had cited the facility for 10 separate violations of state rules governing patient care.
Among the citations, obtained by the Houston Chronicle through a public records request: Kindred nurses weren’t adequately trained or supervised. Patients had been unnecessarily restrained. Others had suffered infections after staff mishandled contaminated materials or failed to properly wash hands. Administrative safeguards weren’t in place to prevent future mistakes.
In 2012, according to one citation, a patient in Kindred’s intensive care unit became disconnected from a breathing machine and was left to die, even as an alarm sounded, alerting staff of the problem. One staffer who heard the beeping said she didn’t know what it meant.
J. David Cross, the chief executive officer of Kindred’s Houston-area district, defended the hospital’s quality of care, noting that the facility exceeds national benchmarks for complication rates.
“We take seriously any issues brought to our attention by regulatory authorities, and work with them to address any concerns,” Cross wrote in an email to the Chronicle. “We share the same goal — to provide quality care to our patients.”
Patton was troubled by the problems she saw but felt she’d begun to make progress. Some nurses had become receptive to her on-the-job training, she said, and hospital leadership initially seemed to appreciate her efforts to instill a more professional culture.
She’d been there seven months when Cris Chapa brought her mother, Manuela, to the hospital with pneumonia.
Patton checked on her daily and saw her condition grow worse over the course of two weeks. The illness put a strain on her frail heart. Her lungs began to fail. So did her kidneys.
Before leaving for the day on March 12, 2015, Patton checked in on Chapa once more. It seemed clear to her that she might not recover.
Patton assumed doctors would soon be meeting with the woman’s family to discuss their options.
The next morning, as she arrived at work, a respiratory therapist grabbed Patton by the arm and pulled her aside: “Oh my God, Linda,” she said. “It was terrible.”
The therapist had been in the room the afternoon before, when Dr. Yassir Sonbol, an interventional cardiologist, tried to insert a catheter in a major vein in Chapa’s neck in hopes of starting dialysis. The treatment might have eased the burden on Chapa’s kidneys — but it also came with risks.
On his first attempt at inserting the line, according to medical records and witnesses, Sonbol couldn’t get the catheter to stay in the vein. So he tried again on the right side, but this time, the wire got stuck, and Sonbol struggled to get it out.
As the doctor fidgeted with the line, Cris Chapa and one of her brothers showed up at the entrance to the hospital room, unaware their mother was being operated on. She said medical staff blocked them from entering and whisked them away: “You can’t be here right now.”
Inside, Manuela Chapa’s heart had stopped as blood spilled from her. The medical team revived her once, but when her heart quit again minutes later, there was no bringing her back.
According to medical records reviewed by the Chronicle, a nurse filled out a consent form for the procedure and printed Cris Chapa’s name on it, but the signature line is blank. Chapa, who’d been legally designated to make all of her mother’s health care decisions, said she was never consulted. The line where the physician is instructed to sign, certifying that he discussed the procedure and risks with the patient’s legal representative, also is blank.
Through an attorney, Sonbol denied any wrongdoing and declined to be interviewed for this story, citing patient privacy concerns. Cross, the Kindred CEO, said he couldn’t answer detailed questions due to pending litigation. He denied the hospital did anything improper in Chapa’s care.
Patton was horrified the next day as she reviewed the medical file and learned more about the incident from others who were there. She figured the hospital would investigate and take action to discipline those responsible. That’s usually what happened after mistakes when she’d worked at hospitals in the Texas Medical Center.
A couple of weeks later, when Patton realized no one had been punished and that the family still hadn’t been told what happened, she said she raised the issue with a superior, but the woman brushed it aside.
“That upset me,” Patton said. “It matters in this business what you do when nobody’s looking.”
A month later, when still nothing had changed, Patton wrote a note to Kindred’s corporate office in Kentucky. Corporate’s response was swift, Patton said: Within a couple of weeks, a manager flew down to meet with her. Only, she wasn’t interested in hearing about the circumstances of Chapa’s death.
“She told me that was none of my concern and to just let leadership handle it,” Patton said.
Instead, the official scolded Patton for sharing her concerns about the incident via email. That constituted a violation of the patient’s privacy rights, the official said. She ordered Patton to take an online refresher course on medical privacy laws.
Soon after that meeting, Patton started hearing whispers from other nurses that her job was in jeopardy.
“At that point,” Patton said, “I’d talked to leadership. I’d talked to corporate. They still hadn’t done the right thing.”
One night, while searching online for ideas on how to resolve the situation, Patton found a study suggesting medical errors are likely the third-leading cause of death in the United States, but the incidents often go unreported. One reason, according to experts: Medical professionals are hesitant to report mistakes, for fear of reprisal.
That was in the back of Patton’s mind in May, when she wrote to the Department of State Health Services, the Texas agency authorized to investigate hospital misconduct, and detailed what had happened to Chapa. She also reported an incident from that February, when Kindred nursing staff failed to monitor a 66-year-old’s blood-sugar after giving medication, resulting in the patient’s death.
Patton signed her name to the letter but asked that her complaint be kept anonymous.
In June, the state sent an investigator to the hospital. Although Texas law requires the investigator’s report be kept secret, the findings from the visit were spelled out in a Centers for Medicare and Medicaid Services citation issued a couple of weeks later: The hospital, according to the federal report, had violated Chapa’s rights by failing to get consent from her daughter before operating. The agency also cited the hospital in the earlier patient death reported by Patton.
A spokesman for DSHS, which has authority to fine hospitals for such violations, confirmed that the agency had substantiated Patton’s complaint, but it took no enforcement action. He said he’s barred by law from discussing the matter in more detail.
The Texas Medical Board, the state agency that licenses and disciplines physicians, conducted its own review and cleared Sonbol of wrongdoing. In a confidential letter obtained by the Chronicle, the board said a full investigation was not warranted because it had received “medical records and affidavits” showing that Sonbol had received legal consent to perform the procedure.
Neither Chapa nor Patton was interviewed by the board, and a spokesman for the agency said he was unable to comment.
Two years later, only one person involved in Chapa’s care has been dismissed: Kindred terminated Patton a little more than a month after the state sent its investigator in 2015.
Hospital leaders told her that her position was being eliminated due to budget cuts, Patton said. But when she requested to be transferred to another Kindred hospital in Houston, she got no response from the hiring manger.
Later, Patton learned from DSHS that her name had been passed on to Kindred, along with her written complaint. She asked the agency about its whistleblower policy but was told there was nothing that could be done.
The Texas law that requires hospital investigations be kept secret includes no such protections for those who step forward to report wrongdoing.
Hours after receiving the email from Cris Chapa in January, Patton picked up her phone and dialed.
“Hello, Ms. Chapa?” she said, then introduced herself.
Patton told her about losing her job and how, a few months later, she’d filed a wrongful termination lawsuit in Fort Bend County, which remains pending. In the suit, she details her attempts to get the hospital to respond before going to the state. In response, the hospital filed a motion denying the allegations.
Chapa, 64, told Patton about the grief she felt after her mother’s death. The sense of guilt that she hadn’t done enough for her. The rage she felt now after learning what had really happened.
It didn’t matter that her mother might not have lived much longer. She didn’t deserve to suffer at the end, Chapa said, and nobody other than her children had the right to
“It matters in this business what you do when nobody’s looking.” Linda Patton, nurse practitioner “As her oldest daughter, it was my job to protect her, and they took that away from me.” Cris Chapa
make that decision for her.
“As her oldest daughter, it was my job to protect her, and they took that away from me,” Chapa said.
At the end of the call, Chapa and Patton made plans to meet in person, and since then, they have become friends. Chapa has taken to calling her “my warrior nurse.”
The two met again last week, this time at a conference table at the law office of Jack McGehee. After hearing Patton’s story, and reviewing the medical records, the lawyer had agreed to represent Chapa in a malpractice lawsuit against Kindred and Sonbol.
The lawsuit, filed last month in Harris County, alleges not only that the hospital failed to get consent before operating on Chapa but that someone altered some of her medical records afterward to conceal what happened.
McGehee believes the facts show that Chapa’s mother “was killed by a procedure that wasn’t warranted and wasn’t consented to.” But taking the case was not a smart financial decision, he said. Texas caps malpractice damages at $250,000, which is about how much it will cost his firm to litigate, McGehee said.
“We don’t expect to make money on this,” he said, then nodded toward Patton: “We’re here because people more noble than myself set an example of courage that’s pretty hard to match.”
Patton batted her hand, dismissing the compliment. She didn’t do this looking for recognition, she said. She initially didn’t even want to talk to a reporter and refused to be photographed for this story, fearing publicity could keep her from finding work again in health care.
She spoke up, she said, only because so many others didn’t.
“In the back of my mind, I kept hoping someone else would,” said Patton, who got her start in medicine two decades ago while serving in the Air Force. “That’s what you keep hoping for, that someone would do the right thing, but that just didn’t happen.”
After losing her job, Patton thought that was the end of it. She’d done her duty.
Then, in December, her mother became ill. Patton went home to Louisiana to be with her in the hospital, watching suspiciously as medical staff took her behind closed doors for heart bypass surgery.
She sat in the waiting room, worried something might go wrong. She imagined how she’d feel if a doctor had made a mistake or attempted a risky operation without her consent and then tried to keep it from her.
“I would want to know what happened,” Patton said, her eyes damp with tears. “You would want to know if it was your mom.”
Later, after her mother had been discharged from the hospital and Patton had returned home to Houston, she sat down at her computer and began to type a letter.
“I to wouldknow what want happened. You would want to know if it was your mom.” Linda Patton