Family unaware no one noticed mother flatlining for 10 minutes

pseligson@newsobserver.comJanuary 27, 2014 

Penny Whitaker hugs her mother, Caretha Whitaker, in 2000.


— The Johnston Medical Center in Smithfield never told the family of Caretha Whitaker the whole story of her death: that her heart stopped in the Emergency Room for about 10 minutes without anyone noticing.

Whitaker died Aug. 25 and her family has for months had lingering questions about her unexpected death.

“I’m upset,” said Penny Whitaker, one of Caretha Whitaker’s four adult children. “Because when we went there that same day that she passed away, they acted as if they did nothing wrong.”

But that wasn’t the case. According to a federal investigation, a nurse improperly left Whitaker alone when she went to care for another patient without telling anyone.

Whitaker’s death led to two investigations: an internal review by the hospital, started five days after she died, and the investigation by the Centers for Medicare & Medicaid Services, or CMS, which got involved after someone filed a complaint.

Family members said no one told them about either investigation.

The federal investigation, a public record, doesn’t name the patient, giving only her age and gender. But only one 66-year-old woman died that day in Johnston County, according to the Johnston County Register of Deeds Office; the time and place of death also match.

After reviewing the investigation, Whitaker’s children say they have no doubt the patient in the report was their mother.

Last week, the Smithfield Herald contacted Johnston Health, the medical center’s parent company, to ask why it never told the family. A few hours later, Penny Whitaker said, a hospital official called her to say that if family members had any questions, they could make an appointment.

The hospital would release only a two-sentence statement, saying it could not comment further because of federal health privacy laws.

“As we have reported, the hospital has taken measures to make cardiac monitoring in the Emergency Department as safe as possible,” the statement said. “We are hopeful to talk with the patient’s family and believe that any discussions about the patient’s personal medical information should be discussed privately with the family.”

Penny Whitaker said she would like to know why the hospital wants to talk to her family now rather than months ago.

What happened that day

At the time of her death, Caretha Whitaker was living in Selma with two of her four children, Mark and Penny Whitaker, and across the street from her other daughter, Caroline Whitaker.

The brother and sister, who have since moved to Raleigh, were helping care for their mom, who suffered from diabetes and kidney disease.

On the morning of Aug. 25, a Sunday, Penny Whitaker woke to find her mom on the floor. “She was talking gibberish,” Penny Whitaker said. “I checked her sugar; couldn’t get a reading. Just said low.”

Whitaker’s children called an ambulance, and the EMS crew took her to the hospital. She arrived at 10:48 a.m. and died at 2:26 p.m. According to CMS’ investigation, the ER staff ran tests during that time, and Whitaker even ate a few bites of food.

Because Caretha Whitaker had been in and out of hospitals in recent years, the family knew the routine and decided to wait to join her until she had a room and was settled in, they said. As they were preparing to drive over, a doctor called to say their mom had died, and they rushed to the hospital.

The primary nurse showed them that their mother’s pacemaker tried to restart her heart three times, Penny Whitaker said. He said her death happened suddenly; their mom had a bite of turkey sandwich still in her mouth. The primary nurse said the ER staff was with her the whole time, Penny Whitaker recalled.

But according to the investigation, Whitaker’s primary nurse went to lunch and handed her off to another nurse. That nurse then improperly went upstairs to take care of another patient without telling anyone.

While Whitaker was unattended, her heart stopped. Somehow, despite the six staff members available in the ER at the time, no one heard the cardiac monitor flatline for about 10 minutes. When her primary nurse returned from lunch, he heard the cardiac monitor and rushed to Whitaker, but efforts to revive her failed.

By the time CMS investigated, the hospital had already added redundancies and new technology to keep this from happening again to the federal agency’s satisfaction.

More questions

Penny Whitaker said she doesn’t understand how a heart monitor could go off without anyone noticing; she has heard those alarms before, and they are loud.

According to the investigation, the alarm would have been “two bursts of five tones every 15 seconds, or continuous tone,” along with a flashing-red alert message on the monitor in Whitaker’s room and on a screen visible to the nursing station. The alarm was definitely on, said Chief Executive Officer Chuck Elliott in an earlier interview.

Mark Whitaker said he asked his mom’s doctor for an autopsy that day and was told one would be done.

But later, as the family was leaving, the primary nurse pulled Penny Whitaker aside, she said. According to Penny Whitaker, the nurse said family members could request an autopsy only if they suspected foul play.

Under North Carolina law, a family can request an autopsy even when a medical examiner doesn’t see a point in performing one. In such cases, the family has to pay for the autopsy. Penny Whitaker said the nurse just said the family couldn’t request an autopsy and one was never done.

The family plans to meet with Johnston Health on Tuesday.

Caretha Whitaker was a lifelong resident of central Johnston County. Before retiring, she worked as a nurse’s aide, her family said, taking care of a paralyzed man. Her husband, Rufus Whitaker Jr., died in 1999. In addition to her four adult children, Whitaker left behind 10 grandchildren and four great-grandchildren.

“She was our big momma,” Penny Whitaker said. “That was our backbone that we lost. We thought we’d have more time with her.”

Seligson: 919-836-5768

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