County to Pay $120,000 in Death of Patient

The Board of Supervisors on Tuesday approved paying $120,000 to the family of a 52-year-old woman who died after drinking from a cup of toxic fluid left by her bedside at Martin Luther King Jr./Drew Medical Center.

As supervisors approved settlement of the lawsuit by the family of Blanca Maldonado. they expressed disbelief at reports that another patient eight years earlier died after drinking another toxic solution erroneously left by her bedside and that the problem had not been corrected in time to save Maldonado’s life.

Supervisor Don Knabe ordered the county’s inspector general for risk management to investigate the case to ensure that a “corrective action plan” is implemented now, “so this does not happen a third time.”

And Supervisor Gloria Molina said that in many other cases, health officials have pledged to correct systemic problems that cause harm to patients but failed to do so.

“You go through this entire process . . . and you have staff that don’t think it’s significant to implement,” Molina said, noting that many employees who fail to fix identifiable problems remain on the county payroll.

Supervisors over the years have repeatedly spoken of the need to prevent errors in the county’s six public hospitals, both to cut down on injuries and deaths to patients and to lower the amount of public money the board must pay to settle medical malpractice lawsuits each year. At Knabe’s urging, the board even created an inspector general last year to ensure that chronic problems uncovered in litigation are corrected.

But medical malpractice cases remain plentiful at the county. On Tuesday, supervisors approved $600,000 more in malpractice settlements in addition to the Maldonado case.

Maldonado went to King/Drew in January 1998 suffering from anemia and complaining of nausea and vomiting. Medical staff members prepared to remove some of her bone marrow to determine whether she had cancer and prepared a liquid, known as Zenker’s solution, for use during the procedure.

According to county documents, medical staff members left the highly toxic solution in an unlabeled cup on a tray by Maldonado’s bedside, but then decided to postpone the procedure. They did not remove the tray, and four hours later Maldonado complained that she had drunk the fluid and suffered severe stomach pain. She died an hour later.

Although hospital officials initially suggested that she had died because of kidney disease, an autopsy found the cause of death to be poisoning by mercuric chloride and potassium dichromate, chemicals in Zenker’s solution.

County lawyers urged the $120,000 settlement, writing in a memo to supervisors that a jury could deliver a verdict of more than $250,000 against the county should the case go to trial. They wrote that medical experts would criticize leaving the Zenker’s solution unlabeled near Maldonado. “These failures exposed Blanca Maldonado to the risk of ingesting a portion of the Zenker’s solution, resulting in her death,” the memo states.

That analysis is strikingly similar to one issued by county lawyers five years ago in a $250,000 settlement of a wrongful death lawsuit filed after a woman died at Harbor-UCLA Medical Center in 1992 because she drank from a bottle of mercuric chloride that had been left by her bedside.

In that case, county documents state that the bottle was left by Amalia Arevalo’s bedside because Arevalo was supposed to fill it with a stool sample to determine the cause of her illness. Though a nurse stated she told Arevalo what to do in Spanish, she left Arevalo alone in the room.

“It was below the standard of care to leave the test kit on the table next to the patient’s bed without supervision and clear instruction on its use and hazards,” county lawyers wrote.

A visibly frustrated Knabe said that Harbor-UCLA issued new plans to prevent the error from occurring in the future but that the health department never ensured those procedures were implemented at other public hospitals.

The other settlements approved by supervisors Tuesday were:

* A $487,500 settlement of a lawsuit brought by a woman whose leg was amputated after a botched surgery at Olive View-UCLA Medical Center in Sylmar.

* A $125,000 settlement in the case of a 14-year-old boy who suffered nerve damage in his legs and feet after being left in a dangerous position while not monitored. In that case, according to county documents, an unsigned note was inserted into the medical record falsely stating that the boy, Sam Kim, was monitored.