Suspicious Hospital Death Probed

Los Angeles County health officials and the Sheriff’s Department are investigating the suspicious death of a woman at Martin Luther King Jr./Drew Medical Center who went into cardiac arrest last Thursday after a hospital staff member left a container containing a highly poisonous liquid chemical mixture next to her bed.

The investigators, county officials said Tuesday, are trying to determine whether the 52-year-old woman--who was suffering from kidney failure--drank from the container, mistakenly thinking it was water or juice. Health officials declined to identify the woman, citing the confidentiality of the investigation.

So far, health officials are uncertain whether the woman drank the substance or if the container was accidentally knocked over by hospital staff members trying to resuscitate her. “A large portion of the liquid [in the container when it was placed in her room] could not be accounted for,” one investigator said.

Dr. Donald C. Thomas III, the Department of Health Services associate director for clinical and medical affairs, said it also was possible that the woman may have died solely from her kidney problems.

But he said investigators believe it is likely that the woman drank at least some of the substance, adding that even a small amount could have killed her or hastened her death.

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“What makes me suspicious is . . . finding this substance proximate to the patient and having them die,” Thomas said. “Nobody can deal with that solution. It’s poison.”

Thomas said investigators are awaiting autopsy and laboratory test results that they hope will tell them whether drinking the liquid killed the patient or whether the concoction triggered the cardiac arrest from which she died.

In either case, Thomas said, the liquid should never have been left in the patient’s room when she was unattended, much less at her bedside within easy reach.

Known as Zenker’s solution, the mixture of formaldehyde, potassium bichromate, mercuric chloride and other chemicals is particularly dangerous to patients with kidney problems “who can’t get rid of potassium,” Thomas said.

The patient, who had undergone dialysis hours earlier, was in another part of the hospital getting a sonogram when the toxic solution was placed in her room. Zenker’s solution is used to preserve tissue taken during bone marrow tests or biopsies, according to Thomas and other health officials. Investigators are still unsure why the dead women would have been scheduled for either procedure.

After the sonogram, the patient was left alone in her room. Hospital staff members returned later and discovered she was experiencing symptoms of cardiac distress.

Thomas said his department’s inspection and audits staff is also investigating whether an inexperienced medical resident left the solution at the woman’s bedside and whether the residents treating her were properly supervised by attending physicians at the hospital.

The health department’s investigators already have begun interviewing medical residents, staff and others about the incident. The Sheriff’s Department is conducting its own investigation because the death was officially deemed suspicious and because of concerns that it was caused by “potential toxic ingestion,” Thomas said.

Sheriff’s officials had no immediate comment.

Dr. Alfred Forrest, the hospital’s associate medical director, said he could not comment in detail because the case is under investigation.

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Forrest did say, however, that the woman’s dialysis was apparently uncomplicated and that it was more than 12 hours later when she began to “have nausea and vomiting, and was suspected of possibly having had an unobserved ingestion of a toxic solution.”

Forrest said: “The patient subsequently became unstable, went into cardiac arrest and died.”

He would not comment on whether the toxic substance was left near the patient’s bedside or why, or on whether a resident was involved.

But Thomas, the department’s top medical trouble-shooter, said the investigation to date shows that one or more hospital residents were caring for the patient.

In the past, inadequate supervision of residents has been a source of concern at the sprawling medical center, and has been specifically cited in patient deaths and complications by independent hospital accreditors, the district attorney’s office’s medico-legal section and the hospital’s staff.

Thomas stressed that it is common for teaching hospitals like King/Drew to allow residents--who are completing their post-medical school specialty training--to treat patients, even with potentially deadly chemicals.

“But you have to be absolutely certain that these people are supervised the way they’re supposed to be,” Thomas said. “They’re not expected to know everything. They are still in training.”

Clearly, however, “there is a procedural issue with leaving the tray [with the solution] in the room,” Thomas said. “I will investigate this to the Nth degree and get to the bottom of it.”