Family unaware that no one noticed mother flatlining for 10 minutes

pseligson@newsobserver.comJanuary 24, 2014 

Johnston Health never told the family of Caretha Whitaker the whole story of her death: that she flatlined in the Emergency Room for about 10 minutes without anyone noticing.

Whitaker died Aug. 25, 2013, and for months, her family has 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. We asked questions, and they said, ‘No, we was here with her every step of the moment.’”

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 just five days after she died, and the investigation by a federal agency in October.

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 Whitaker’s death.

The Smithfield Herald reached out to Whitaker’s family, and after reviewing the investigation documents, they said they have no doubt the patient in the report was their mother.

Last Tuesday, the Smithfield Herald contacted Johnston Health 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.

“My mom died in August,” Penny Whitaker said. “Here it is, January, which is almost six months. Six months done passed by, and we never heard anything else from the hospital. Then all of a sudden today, they call us.”

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

Just across the street lived her other daughter, Caroline Whitaker, and son-in-law, Samuel Smith.

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.”

The family called an ambulance, and the EMS crew decided to take her to the hospital.

The family waited to go to the hospital because they wanted to give their mom time to settle in.

Because Caretha Whitaker had been in and out of hospitals in recent years, the family knew the routine, Samuel Smith said. “They admit her in and then get her room,” he said. “Then they call us, let us know what her room number is, then everybody go out there.”

As the family was preparing to drive over, a doctor called to say their mom had died. The family then rushed to the hospital.

“They went through all the details of how everything had occurred,” Penny Whitaker said.

The primary nurse showed them that their mom’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 an investigation by the federal Centers for Medicare and Medicaid Services, 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 unattended, Whitaker flatlined. Somehow, despite the six staff available in the ER at the time, no one heard the cardiac monitor go off for about 10 minutes. When her primary nurse returned from lunch, he heard the cardiac monitor and rushed to her, but efforts to revive her failed.

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, she said.

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

Mark Whitaker said he asked his mom’s doctor that day for an autopsy. The doctor said 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.

But under North Carolina law, a family can request an autopsy even when a medical examiner doesn’t see a point in performing one. In those cases, the family has to pay for the autopsy.

But Penny Whitaker said the nurse never mentioned money; he just said the family couldn’t request an autopsy. In any event, one was never done.

Caroline Whitaker said she is haunted, not knowing if her mom could have been saved if a doctor or nurse had noticed her flatlining earlier. And the lingering question: What if the family had been there to tell the doctors when she flatlined?

“It just hurts me to my heart because I feel like she went through something that she didn’t have to go through,” Caroline Whitaker said. “She was by herself when she’d never really been by herself.”

The family plans to meet with Johnston Health on Tuesday. Though the family gave permission for a reporter to attend, Johnston Health said it would not meet with the family if a reporter was there.

‘Our backbone’

Caretha Whitaker was her family’s backbone, her children said.

Also known as “Wicky,” a childhood name, Caretha Whitaker was a lifelong resident of central Johnston County. She had four adult children: two sons, Mark and Kim, and two daughters, Penny and Caroline, plus 10 grandchildren and four great-grandchildren.

“She’s the one that kept everybody together,” Mark Whitaker said.

Whitaker’s husband, Rufus Whitaker Jr., died in 1999. Before retiring, Caretha Whitaker worked as a nurse’s aid, her family said, taking care of a paralyzed man.

“She was a happy woman,” Mark Whitaker said. “She loved family. She loved family time.”

“She was our big momma,” Penny Whitaker said. “That was our backbone that we lost. We thought we’d have more time with her. She wasn’t that sick.”

Seligson: 919-836-5768

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