Hospital Medical Mistakes Cited in Marine’s Death

Tragic and unnecessary death of Marine hero demonstrates need for better medical accountability for malpractice in hospitals.


TAMPA – Investigators say the death last year of a 21-year-old Marine at James A. Haley VA Medical Center might have been prevented if doctors had conducted more thorough tests.
Investigators also said that the VA and the Department of Defense should use the findings by the VA inspector general to better educate doctors on how to treat the type of “blast injury” that has become prevalent in Iraq and Afghanistan.
Speaking of troops injured in the war zone, investigators said they found no evidence that Haley’s acute care staff, “including its specialty medical and surgical consultants, had been properly prepared for these patients.”
Lance Cpl. Jonathan E. Gadsden of Jamestown, S.C., was severely injured in Iraq last August by a roadside bomb. He was on the mend at Haley and was tentatively scheduled to be discharged, but he died unexpectedly of bacterial meningitis Oct. 22.
Bacterial meningitis is an infection of the fluid in the spinal cord and the fluid that surrounds the brain. Doctors at Haley failed to diagnose the condition before his death, the report said.
“An underlying theme that emerges is that many of the (Haley) clinical staff simply did not grasp how inherently fragile this patient was,” the report released Wednesday said, resulting in “less intensive diagnostic evaluations.”
A doctor who cared for Gadsden told investigators that he now has a better appreciation for patients who have been injured in Iraq.
In response to the findings, a peer review at Haley concluded that even if doctors had done everything right, Gadsden’s head and body injuries were so extensive that “he was therefore facing a 70 percent mortality risk.”
Gadsden’s family, which has been critical of Haley, could not be reached for comment.
But Rep. C.W. Bill Young, who helped push for the investigation, was not happy with the treatment Gadsden received.
“Obviously, some things were overlooked in Gadsden’s case,” the Indian Shores Republican said Thursday. “Had things been thoroughly investigated, his life could have been saved.”
Young noted that doctors at Walter Reed Army Medical Center and National Naval Medical Center in Bethesda, Md., have successfully treated cases of meningitis. Young has asked VA Secretary Jim Nicholson to review the quality of care at Haley.
In a statement, Haley spokeswoman Carolyn Clark said that the hospital had implemented improvements recommended by the inspector general, such as having better communication between the VA and military hospitals.
When Gadsden was admitted to Haley on Sept. 30, he appeared to be doing fine.
According to the first progress note that afternoon, clinicians found him “to be alert, cooperative and oriented to person, place, month, and year.”
“He reported having a good appetite, and denied having any pain while lying at rest.”
During his stay at Haley, Gadsden complained of intermittent abdominal and back pain. On Sunday, Oct. 17, he appeared “shaking and restless,” but was granted a day pass.
“The pass included a visit to a Wal-Mart, the mother’s hotel room and a fast food establishment,” investigators said.
Zeada Gadsden did not describe any unusual symptoms in her son during the outing. But that evening, after Gadsden returned to the hospital, staff noticed “increased confusion” and “increased tremor/shaking, restless.”
A resident recommended a neurosurgery consultation, but canceled it several hours later.
Investigators said Gadsden’s condition worsened and he hallucinated. On Oct. 19, he suffered cardiopulmonary arrest and other complications.
A followup exam concluded that “the patient had suffered severe anoxic brain injury, i.e., injury due to prolonged lack of oxygen to the brain.”
He was clinically brain dead, the report said.
On Oct. 22, at 2:15 a.m., with his family at his side, Gadsden was taken off the ventilator.
He died five minutes later.
In general, investigators said the quality of care Gadsden received at Haley was “high.” But there were problems – not all of them Haley’s fault. For example, Haley said it did not receive Gadsden’s complete medical file from Bethesda, which would have shown earlier complications.
Investigators also found that once Gadsden’s condition began to deteriorate, Haley doctors did not conduct thorough exams. For example, he was seen only once by an infectious diseases specialist before Oct. 19, the day he went into cardiopulmonary arrest.
The infectious diseases section response “lacked depth of research into the patient’s recent medical history and did not provide more than a general outline of how to proceed with the evaluation and management of this most complex patient,” the report said.
It added, “The plan that was provided did not adequately consider the possibility that this patient could have an infection in the central nervous system, even though the patient had sustained skull and brain injury that had required recent neurosurgery.”
A review of earlier medical exams at Bethesda “should have altered the diagnostic evaluation and treatment plan and may have changed the clinical outcome in this case,” the report said.
Gadsden’s confused mental state also should have been a warning sign, investigators said.
Investigators concluded that the Haley staff was not sufficiently trained in the type of blast injuries seen in Afghanistan and Iraq and recommended that the VA provide additional training for staff nationwide on blast injury patients.
Dr. Jonathan Perlin, VA undersecretary for health, responded in the report that additional training – in conjunction with the Department of Defense – already was under way.