Dozens of Mistakes Caused Death of Young Hospital Patient, Court Rules

Documents obtained by NBC Bay Area’s Investigative Unit show medical staff at UCSF nearly quadrupled a young patient’s opioid medication and then failed to monitor him with a pulse oximeter, a simple medical device that would have alerted them if his blood oxygen level fell to a dangerously low level. Jessica Aguirre reports.

Stay Connected:

Catch up on all the day's news:

Download our mobile app:

Watch us on OTT:

[Ormy-]

I'm a nurse in Canada
This happens alot more than you would like to think. The only difference with this case is that it got investigated. Many don't.

[FreedomofSpeech]

My father had open heart surgery and was not monitored correctly or given ANY PAIN MEDS, he did not want to be a bother and told me to say nothing. I was not having it. Look after your family when they are hospitalized and speak up. This is so tragic.

[TentinQuarantino_]

How horrifying! His poor sister must carry such unwarranted guilt.

[katrinadentino-reyes]

$250, 000 or 2M - regardless of the amount it will NEVER amount to the pain this family has the endure from the poor care this family received while their son was UCSF care. Their son was overdosed, their son was not monitored, their son was KILLED. And the fact that UCSF still after expert witnesses and medical charting doesn’t want to admit fault - is just despicable and disgusting. I feel for this family in an immense way. I pray they heal and Shame on you UCSF for not accepting accountability for your wrongdoings.

[katibarrett]

How much of these errors were caused by uderstaffing because hospital admin wants to line their own pockets with money instead of hiring more nurses?

[erint]

My father had a heart attack last month, had to get a stat procedure done in cath lab where he had a stent placed and thrombectomy for 99% occlusion of one of his coronary arteries. I went to visit him in recovery and he was on NO monitoring and also on a nitroglycerin drip for residual chest pain (which also decreases blood pressure). Luckily I’m an icu RN and when I asked the nurse caring for him why isn’t on monitoring she claimed “oh he doesn’t have to be”. I went straight to the charge nurse with my concerns and requested that they take his vitals and keep him on monitoring until he is in the pcu (he’d been waiting hours for a room and had to wait in recovery). When they took his vitals his blood pressure was already dipping below therapeutic. Imagine that someone has a heart attack and the incompetent thinking of some healthcare staff is that they don’t need any sort of vital sign monitoring (no ekg, no oxygen sats, no bp). And I say this as a nurse, sometimes the critical thinking in some facilities can be pathetic.

[tinaa]

What a tragic story. Ugh, can you imagine the guilt his sister feels?!! My brother donated a kidney to me ( University of Maryland in 2016), and I would feel like it was my fault if something had happened to him during his recovery.

[koleful]

As a medical doctor myself I HATE the hospital as a patient and I” paranoidly” go over every patient I see. I’m the doctor who does too much.
When I was having my baby with so much prayers and GOD, my Husband also a doctor with over 10 years of experience (he used to be a paediatric resident but later went on to do family medicine) NEVER left my side. I pray everyday never to be admitted to hospital.
I pray for healing for this family

[pjsmith]

How terribly sad!!
As a former RN, I am not at all surprised that this young man died.
I trained and worked at a teaching hospital and the mistakes I saw were appalling. And covered up.
Between that and the bullying of my nurse colleagues, I left nursing forever.
And I am highly suspicious of all Doctors and nurses, sad to say.
And many times, with my children, we were assigned Specialists - many not very competent and one who put one of my son’s life in jeopardy. Terrifying.
Complained later to the Medical Body of which he was a member.
He simply lied about everything and - case closed. Still practicing in the same Specialty. 🥺

[tessaelto]

When I was in rehab at 16 a nurse gave me 3x the dose of my anxiety medication I needed, about 8 hours to early and I passed out in the hallway. When I came to the nurse was yelling at me for accepting the medication when I didn't know what any of it was and saying "I know your kind, you need attention".. Then later on that day she gave me a sob story of how her husband died last year and to please forgive her. Some people need to lose their jobs and honestly I really should have formally reported her

[Jane_]

When my grandmother was hospitalized, our saving grace was my brother's wife, a registered dietician with basic medical knowledge. She routinely called out a variety of errors on the part of my grandmother's medical team (including not reattaching her nutrient bag and leaving her without nutrients for 24 hours while on life support) and this was before the pandemic. When my grandmother needed help, it regularly took 45 minutes to be seen by the respiratory therapist or nurse. It's profitable to have minimal staff and this is the level of care it leads to. I indirectly know two people who were killed by medical errors in hospitals. We need an overhaul of our medical system.

[thegatesofdawn...]

Not to mention he had had another powerful pain killer before Dilaudid.
5 hours unmonitored, no oxygen alarm.
I sorry for the sister and Mother.

[ninamahkuk]

This is why I'm terrified any time I go to the hospital. I'm always questioning the nurse about what she's putting in my IV and how much and if it's going to interact with any of my current meds. I'm an absolute nightmare of a patient. I value my life too much.

[jennifern]

Hospital staffing has run off most experienced floor nurses that would catch this kind of thing. You can’t make enough policies to replace expert level nurses. Most hospital nurses have 1-3 years only.

[frayydoh]

I'm sorry for the loss of your son. Folks, medical malpractice is real and it happens more often than you think. Strive for better pay, better work ethic and environment.

[tahj]

I’m a nurse and I can’t understand why another nurse wouldn’t monitor the patient!! 😡😡 Just
last week I had a patient come up from the ER. Her vitals were stable when she got to our floor. I read in her chart that she was a diabetic and saw fried chicken in the room when I entered. The ER failed to tell me that they also found her to be hypoglycemic. Patient told me they gave her food but I didn’t see where they rechecked her blood sugar after giving food. I did see that they gave her IV glucose. I check her blood sugar and it’s 749! 😔
Moral of the story, ASSESS YOUR PATIENTS!

[wendyhutchinson]

I thought that $2 million wasn’t enough, and then when they decreased it to $250, 000… I’m speechless and heartbroken for this family. 💔😞

[KaeEssKlassik]

My mother got her transplant at this hospital and we had no issues. I feel like this man’s team completely dropped the ball. I was under the impression UCSF was the best of the best. Apparently I was wrong. But they did treat my mother pretty well in 2010 when we were there. I just wish this man received the same awesome treatment my mother received.

[micheleboyle]

I remember after my last c- section I was put in a utility closet because the hospital didn’t have anymore recovery room space and no one checked me for hours. Fortunately I was fine because my then husband who also is a nurse, took care of me. There are so many things that can and do go wrong! Poor guy and sorry to his lovely family for their loss🙏🏻

[Arialiszt]

In the state of California if a patient is hooked up to a PCA pump (self administering pain pump) by law they HAVE to be on a pulse-ox monitor. Anyone doing direct patient care in California knows this and this was so much more than an oversight.