Two days ago (May 19th) Sorry Works! shared the story of Dale Ann Micalizzi and her yearning for an apology from the hospital where her son died 12 years after his death. In asking permission from Dale to share her story with Sorry Works’ readers, Dale sent me a separate post from her blog entitled, “The Letter that took me ten years to write.” Dale said this letter “has been shared with thousands of attorneys and seems to have made an impact.” Hopefully more many attorneys along with healthcare and insurance professionals will read this letter today. See below.
September 11, 2011
Dear Anesthesiologist, Orthopedic Surgeons and Hospital CEO: (names removed from this post)
You may remember our youngest child, Justin. He was eleven. You cared for him ten years ago. He presented to you on Jan. 15, 2001 for an incision and drainage of a septic ankle.
We believe that the surgery was performed (primarily by the orthopedic resident) during which time Justin experienced a series of cardiac arrests accompanied by a pulmonary hemorrhage from the endotrachael tube. He was transported to the PICU at another facility (name removed from post) in grave condition and died that next morning after being removed from life support with no hope of survival. His brother and sister were asked by the chaplains to be present to say good bye. Being teenagers at the time, this was a life changing and difficult journey for them and his entire family, friends and community. Traumatic, unexpected loss and grief are the most unbearable.
Upon our arrival home, the coroner’s office called stating that “something was not right” and that we should seek an attorney.
With the help of a cardiothoracic surgeon, we retained an attorney to help us find answers. Litigation was chosen because the multiple attempts to speak with you honestly about the care that our son received from you was not taken seriously. The silence was deafening. Although, deaths may be a common occurrence for physicians, they are not for parents. Children are more than blood and bones. If you have children, you are aware of this. Parents need more than a simple answer of “we have no idea” when their child dies. The better option for all of you in the future may be to tell parents, “We have no idea what happened but we will do everything in our power to find out.”
You may remember the depositions. We attended all of those meetings and listened carefully to your words as we remembered every detail prior to the OR. You may not know that I was also questioned for approximately 7 hours about the care of my son leading up to this event. I must tell you that although my attorney said that a mother has never been more prepared and caring, that I found that experience to be cruel and inhumane. I did nothing wrong and I loved my son more than words can explain. As I learned from my visit to professors at a NY Law School, questioning the parent to such an extent was simply a tactic, albeit inhumane, to have the case dropped.
Listening to your heart instead of your attorney’s jargon may have been a better option for all of us. I refuse to believe that physicians are lacking, to this degree, in humanity which is why I continue to work with them. It is difficult to face a parent after a child dies in your care but it is a responsibility that comes with the territory.
I have worked tirelessly for the past ten years trying to promote pediatric patient safety and transparency in medicine. On this quest, I have had the pleasure of working with some of the most brilliant of national healthcare leaders and many anesthesiologists and surgeons. Because of these connections, I am allowed behind the scenes of healthcare that most parents or patients would never see. They trust me.
I received a call from one of these physicians recently; nine years, nine months and four days after our son’s death. He said that a colleague of one of yours stated that he couldn’t live with himself any longer knowing that I was still searching for the truth. He went on to say that all of you, and your attorneys, knew from the beginning that Justin was overdosed on Phenylephrine. He said that the physician had reached for the wrong medication in error and used it in overdose proportions. I shared this new information with all of the physicians that have helped me over the years. Learning from the event is important to me. My child did not die in vain.
A newly released IHI whitepaper that I’ve assisted with, “Respectful Management of Serious Clinical Adverse Events” may be beneficial to your practice. You can find the document on their website. I have also co-authored a published article in Peds Anesthesia, “What happens when things go wrong?” and also a paper with Marie Bismark MD, JD, “The power of Apology.” I’ve assisted with another article for closed claims, “Physician Communication Skills Decrease Malpractice Claims” and have written for a Joint Commission book on compassion in healthcare, along with several others projects.
I have presented at Yale to third year Medical Residents, NRC Picker, IHI, Loma Linda University, NJ Council of Teaching/Children’s Hospitals, LA County Health Dept., Health Management Associates, and many other healthcare organizations, nationally. I am co-chair for the IHI forum this year where my foundation has provided ten scholarships for health caregivers working with under served pediatric populations. You may donate to my work if you chose to. The link is below.
Although this physician informant’s information was troubling, it was also healing. You see, parents blame themselves when something happens to their child. It was our duty to keep him safe. You may not understand this but I could literally feel the burden of the unknown melting from my shoulders even though I have yet to hear the rest of the story. Justin was our child and I am grateful to the physician who finally had the courage to tell me a bit of the truth.
Forgiving you for withholding this information from me and my family has been difficult. I will never forget the events of that day or following, but I am getting closer to accepting the truth as an error or an accident that was poorly handled. I never believed that anyone meant to harm Justin.
My hope would be that fear of litigation will not prompt you to repeat these poor choices if tragedy should strike another family in your care. Your patients deserve better. We trusted you to tell the truth and to do your best. Perhaps, someday you will be able to share Justin’s story with your students so that they can learn from your mistakes and another child’s life can be saved.
Dale Ann Micalizzi
Justin’s HOPE at The Task Force for Global Health