In reality, government inspectors said, they found no evidence that anyone ever checked to see whether Grassini was breathing that night.
By then, Lawrence Grassini had long since hired independent medical experts to review his son's medical records. All four experts identified problems with the hospital's handling of his son's treatment and concluded in separate reports reviewed by The Times that Leo Grassini's death could have been avoided.
"The failure to monitor Leo's vital signs is an egregious departure from basic standard of care and resulted in the death of this 26-year-old man," San Bernardino County chief medical examiner Frank Sheridan wrote in an opinion dated Oct. 27, 2007. Sheridan called for an investigation as "definitely necessary so that others may be protected from such appalling care in the future."
'I was shocked'
After getting the expert opinions, Lawrence Grassini, who has not sued Las Encinas, had one of his law partners send letters to state and federal regulators in November 2007 and again in March 2008, urging them to investigate Las Encinas "so that further and future predictable deaths and injuries could be avoided."
In August, Grassini read the Times report of the deaths of Clyburn and two other patients.
"I was shocked, and mad, and so sad," he said.
A week later, he received the results of a state investigation into his son's case, nearly 21 months after his son died. Government inspectors faulted Las Encinas for failing to monitor the young man. Of the worker who was supposed to be checking Leo's vital signs, they reported: "There was no documentation or other evidence that she had been directly observed or had otherwise demonstrated competency" in performing her job.
Until Arline Clyburn was contacted by The Times, no one had told her about Grassini's death.
In December, she and her husband sued Las Encinas for wrongful death and negligence. The hospital has not yet responded, her lawyer said.
"When this happened in 2006, why didn't they initiate careful and appropriate vital signs checks?" Clyburn asked. "Why are they against doing what they need to do to ensure patient safety?"