Patient Killed by Poison, Tests Find

Blanca Maldonado went to Martin Luther King Jr./Drew Medical Center complaining of weight loss and anemia, and died from drinking from a glass of poison left on her night stand by an inexperienced medical resident.

When the incident was disclosed in The Times in January, hospital officials suggested that the 52-year-old woman might have died of complications from kidney disease, which was diagnosed after she was admitted and for which she was given routine dialysis.

But on Wednesday, county health officials confirmed that she died Jan. 7 as a direct result of drinking the highly poisonous chemical mixture known as Zenker’s solution, which includes formaldehyde and mercury.

It is so toxic, they said, that Maldonado was dead within two hours of taking a drink, despite staggering to a nurse’s stand afterward, pleading for--and getting--help.

“She did drink it,” said Health Services Director Mark Finucane. “Absolutely, that’s what caused her death.”

He and other top health department administrators said lab tests done in conjunction with a coroner’s investigation found lethal levels of the toxic chemicals in the woman’s body.

Asked how much of the solution Maldonado drank, Assistant Health Services Director Donald C. Thomas said: “It doesn’t matter. It is such a toxic substance that any [amount] is enough.”

As of late Wednesday, Maldonado’s family had not been officially informed of the autopsy results, said granddaughter Iris Majia, 22.

“The family is very upset. Now we are scared to go to a hospital,” she said. “If you can’t trust doctors, who can you trust?”

A top hospital administrator, who spoke on condition of anonymity, expressed anger at what he said were continuing and unfair efforts to hold the medical center’s staff responsible for the woman’s death.

“It’s like if I parked my car outside and you ran into it and killed yourself, or if I left a knife out and you killed yourself. Why is that my fault?” asked the administrator.

Maldonado had undergone dialysis hours earlier, and she was in another part of the hospital getting a sonogram when the solution was placed in her room in what investigators say was a benign-looking specimen container.

They suspect that she drank it unwittingly, thinking it was water or juice left on the night stand within easy reach.

In fact, Zenker’s is a fixative solution. It had been left in Maldonado’s room to preserve bone marrow that was to have been taken during a biopsy that had been scheduled to determine whether cancer relating to Maldonado’s kidney problems was present, Thomas said.

The resident--a young doctor recently out of medical school--left the biopsy tray on the patient’s night stand, but the procedure was called off. Health officials had no comment on whether the resident knew that at the time.

When Maldonado was returned to the room, medical staff left her alone without removing the tray or the solution, Thomas said.

Soon, Maldonado began to suffer from nausea and vomiting and alerted nurses, who called a “code blue” emergency response. Although staff responded in a matter of seconds, according to Thomas, the patient went into cardiac arrest and died.

Asked if the staff could have provided Maldonado with some kind of antidote, Thomas said: “I am not sure that anything could have been done to save the lady,” given the toxicity of the solution.

In addition to the highly poisonous formaldehyde and mercuric chromide, the solution contained potassium bichromate, which is extremely toxic for anyone with kidney problems, Thomas said.

The disclosure is sure to raise more questions about the quality of care at the troubled public hospital and trauma center in Willowbrook.

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

Maldonado’s death has triggered a special visit by investigators from the Joint Commission on the Accreditation of Health Care Organizations, the Oakbrook Terrace, Ill.-based group that oversees quality control at public and private hospitals nationwide.

The investigators spent Thursday and Friday at the hospital and will be preparing a report that could result in discipline against the hospital or a cutoff of its Medicare and Medi-Cal funds, Thomas said.

Meanwhile, officials have sealed records in the case in anticipation of another multimillion-dollar lawsuit against the hospital and the beleaguered Department of Health Services, which in recent months has settled other major malpractice cases for millions of dollars.

So far, no one has been disciplined over Maldonado’s death, Thomas and other health officials said.

Both Finucane and Thomas said the comments about the case by the hospital official angered them.

“Any institution, and that includes King/Drew Medical Center, has to accept responsibility for the actions of its medical staff and employees. And I don’t think blaming a patient advances the interests or the reputation of the institution,” Finucane said.

But he and hospital officials said the employee’s remarks do not reflect the hospital’s position, which is that the incident has highlighted problems that need to be corrected.

“Certainly this is a very tragic event that we must and have learned from,” said King/Drew administrator Randall Foster, who added that the hospital has implemented a series of reforms aimed at preventing a recurrence.