Owning Up to Fatal Error Took a While : Patient Died After Receiving Wrong Medicine, but Nurse Got a Clean Bill of Health

What do you tell the family of a terminally ill cancer patient whose death later turns out to be the result of a medication error?

FHP Hospital in Fountain Valley is faced with some good questions in just such a case, not only from the family but from state investigators. Moreover, there are troubling dimensions to the case about the evaluation and licensing of a nurse who hospital officials say mistakenly grabbed the wrong bottle off a shelf.

Francis J. Johnson, a Garden Grove woman suffering from breast cancer, died in November after a nurse, identified recently by the hospital as Maureen Daubert, administered a lethal dose of potassium chloride. The hospital now says it fired the nurse but owned up to the nursing error only recently, after conducting its own investigation and expressing uncertainty publicly about the cause of death for some time.

But a hospital vice president, in acknowledging only recently that the nurse had quickly realized her error and tried to revive the patient, seemed to confirm the strong probability that some kind of cover-up might have occurred.

After all, how much uncertainty could there have been, given the facts, and why did it take so long for the hospital to come clean?

Indeed, a hospital physician had signed the original death certificate, attributing Johnson’s death to her cancer. It obviously was a misleading statement that resulted in the postponement of a crucial coroner’s investigation into an accidental death--which would have been required under the circumstances.

The coroner’s office only recently was able to formally amend the death certificate.

And then there was this astonishing development: Although the hospital says it fired Daubert in November after the death, she received a favorable evaluation for a period as recently as April.

Because no formal accusations were filed against her, her California nurse’s license was listed as “clear,” thus enabling her to get a job at the Veterans Administration Medical Center in Lebanon, Pa., where she found work in May.

Because of FHP’s tardiness in owning up to the accidental death, the California Board of Registered Nursing has been delayed in its investigation of the nurse.

The hospital, by signing off on an erroneous death certificate, may have put off its day of accounting. However, it succeeded in raising some troubling questions that now must await the findings of state investigators.