'We are all hurting': Families of Mount Carmel patients say they’re reliving loved ones’ deaths

Families of patients say they're reliving loved ones' deaths
Families of Mount Carmel victims find themselves asking "what if?"
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COLUMBUS – Some of them have only vague memories of Dr. William Husel.

Others have sharp, vivid recollections of the man who they say told them their loved ones were dying and recommended that they remove life support.

Some thought their loved ones died of natural causes.

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Now they have doubts after receiving phone calls from the hospital saying their loved ones were given too much pain medication.

In their first interview in a group setting, the families of six Mount Carmel patients spoke to 10 Investigates about what they’ve learned in wake of the scandal – in which 34 patients are believed to have received excessive doses of pain medications. Twenty-eight of those, the hospital says, received potentially fatal doses.

The families discussed with 10 Investigates the lingering questions that still plague them – including why and how did this happen?

“It's horrifying. It's one thing to lose a parent or a loved one, but then to find out that that happened it's unfair … it's unfair of all of us to have to relieve this,” said Lisa Coleman, whose father, Jim Allen, died at Mount Carmel West in May of 2018.

A 10 Investigates review of Allen’s death certificate shows he died from septic shock. But his medical records from the hospital show that he received 1,000 micrograms of fentanyl and 6 milligrams of Versed.

And records released this week by state health inspectors – who conducted site surveys at Mount Carmel West and St. Ann’s hospitals – noted that the hospital “failed to ensure a system was in place to monitor and prevent large doses” of medication from being accessed via an override function on the hospitals’ medication dispensing machines.

In 24 of the 27 patient cases state health inspectors reviewed, Dr. Husel used an override function to gain access to large doses of medications.

All of the families 10 Investigates interviewed recently had loved ones who received their pain medications via an override.

“I almost feel like a fool. I feel like I should've questioned or something. Or how could I let this happen? So that's a struggle that we deal with now,” said Amy Pfaff, whose mother Beverlee Schirtzinger was one of two Mount Carmel patients to die on October 9, 2017

Amy’s brother Andy Schirtzinger says their mother was in the hospital initially for a liver biopsy but her health deteriorated. He says she died within 11 hours of arriving there.

Beverlee’s medical records show she received 500 micrograms and 4 milligrams of Versed, which civil attorneys have argued can have an accelerating effect and reduce a person’s respiratory function. Records released by CMS show that Schirtzinger too was given drugs that were accessed by Husel via an override of Mount Carmel’s medication dispensing machine.

“It should have happened naturally the way death should happen, not by another human being. Let alone a doctor that you trust,” Pfaff told 10 Investigates, at times choking back tears.

Albert Bellisari recalled getting the phone call from a Mount Carmel doctor last month. His sister, Joanne Bellisari, a 69-year old auxiliary nun, died at Mount Carmel West in 2015. Bellisari, who is Catholic, said he felt like the hospital violated his family’s trust. They had patronized the hospital before, he says, because of its Catholic philosophy.

"You don't expect a Catholic hospital to not give someone the dignity of death – some dignity in their dying,” Albert told 10 Investigates. “Giving fentanyl is not – you do that to people on death row."

Albert said he remembers being told his sister's organs were shutting down and that she couldn't breathe on her own.
He also said remembers talking about removing her ventilator but does not remember discussing pain medication.

“Why the shot? When I learned that the amount was so high, then I started getting angry. Then anger took over, learning more about the doctor and how the whole protocol is supposed to work. It wasn't working at Mount Carmel. It couldn't have been,” he said.

Ed Lamb, Mount Carmel’s CEO and President, has released two video statements – one that was disseminated to the public and another sent exclusively to Mount Carmel’s 11,000 employees (which 10 Investigates first obtained) – detailing that the hospital’s
“processes in place were not sufficient to prevent these actions from happening.”

The hospital fired Husel in December and placed 23 caregivers – including 14 nurses, 6 pharmacists and three additional employees including members of management on administrative leave.

Pharmacy Janet Whittey also announced that she had left the hospital as of February 5. It was not clear if Whittey was fired or quit. The hospital said it didn’t comment on individual employment matters – which isn’t true – it confirmed Husel’s firing to reporters.

Late last month, CMS notified Mount Carmel that it had been placed in “immediate jeopardy” status and it was in danger of losing its Medicare funding unless it submitted plans of correction for both Mount Carmel West and St. Ann’s hospitals.

Follow-up site visits by the state department of health are expected as Mount Carmel works with CMS to try to retain its Medicare funding and remove its “immediate jeopardy” status.

Thirty-three of them received excessive doses of medications at Mount Carmel West and one occurred at Mount Carmel St. Ann’s in Westerville.

The hospital fired Dr. William Husel on December 5.

Husel and his attorneys have declined to comment. But in court motions filed this week, civil attorney Gregory Foliano makes arguments regarding some of the patients’ conditions while at the hospital. For example, he alleges that Jan Thomas suffered a stroke after arriving at the hospital and that "her presentation was not compatible with life or any meaningful recovery." And that another patient, Jeremia Hodge, had no heartbeat when she arrived and later died in the intensive care unit. Foliano has argued he wants the civil cases stayed until a pending criminal investigation is resolved.

Husel is accused of ordering potentially lethal doses of fentanyl to near death patients who were receiving intensive care. Husel, along with nurses and pharmacists, have been named in several wrongful lawsuits - accused of hastening the deaths of these patients through ordering or administering the powerful painkillers.

Mount Carmel CEO and President Ed Lamb has said the amounts were “excessive” and that the hospital has changed its policies “to ensure this doesn’t happen again.”

10 Investigates has reported that in several of the cases, attorneys allege that Husel bypassed the pharmacy by declaring emergency situations while removing ventilators from patients allowing him to order large doses of fentanyl.

A Mount Carmel employee who came forward this week said what happened was a “systemic failure” – adding that the hospital lacked internal controls or redundancies that would have prevented medical errors from reaching patients.

The employee, who asked not to be identified for fear of reprisal, said in certain situations the pharmacy was unaware that Husel was ordering large doses of fentanyl to be used for patients who were being removed from ventilators.

The hospital confirmed to 10 Investigates last week that among its policy changes – it now requires that nurses and physicians receive pharmacy approval before administering medications during the removal of ventilators.

Attorneys have also alleged that the hospital’s internal system of checks and balances failed to stop the deaths sooner and that nurses and pharmacists should have challenged Husel’s orders.

10 Investigates has put together a comprehensive timeline of patient deaths and allegations against Dr. William Husel, Mount Carmel Health System and its employees. The following information is based on interviews, court filings and medical records compiled by 10 Investigates:

September 2014 – Patient suspected of receiving excessive dose of fentanyl dies at Mount Carmel West Hospital. The attorneys representing this person have confirmed the date but have not released the person’s identity.

March 1, 2015 – Patient Jan Thomas dies at Mount Carmel West Hospital. Her medical records show she received 800 micrograms of fentanyl. Her family’s attorney, David Shroyer, and son Chris Thomas, told reporters that Jan Thomas had a previous hospital stay prior to being taken to Mount Carmel West on February 28, 2015. She died on March 1, 2015. Shroyer says she was given a lethal dose of fentanyl as she was being removed from a ventilator.

May 10, 2015 – Joanne Bellisari, 71, an auxiliary nun was given 1,000 microgram push of fentanyl through her IV, her medical records show. Her attorneys allege in their wrongful death lawsuit that Bellisari was given a “grossly inappropriate dose.” The attorneys allege, as they have in other patient lawsuits, that Mount Carmel’s electronic medical records failed to flag or alert Joanne Bellisari’s medical providers that such an order appeared to be in error. Alternatively, the complaint read, “this excessive dose of fentanyl was flagged and/or alerted by the system as inappropriate, but Defendants ignored the alerts because the order was intended to hasten the termination of Joanne Bellisari’s life.”

October 9, 2017 – Six patients are alleged to have died between Oct. 9, 2017 and Dec. 11, 2017, including two separate sets of patients who died during the same shifts, attorneys allege.

Timothy Fitzpatrick and Beverlee Schirtzinger were the two patients identified by their attorneys who both died on October 9, 2017.

December 10, 2017 – Patient Larry Brigner dies at Mount Carmel West Hospital. A lawsuit filed says he received 500 micrograms of fentanyl.

December 11, 2017 – Janet Kavanaugh dies at Mount Carmel West Hospital after her attorneys allege that she was given 1,000 micrograms of fentanyl through her IV. The attorneys allege that both Kavanaugh and Brigner died on the same overnight shift.

April 1, 2018 – Jeremia “Sue” Hodge died at Mount Carmel West Hospital. Her attorneys allege in a wrongful death lawsuit that she went from the cath lab to the ICU. Her sons had a conversation with Dr. Husel about her health and the family made a decision to withdraw life support. She was given a dose of fentanyl believed to be in excess of 500 micrograms.

May 28, 2018 – Jim Allen received 1,000 micrograms of fentanyl, according to his medical records. He died the same day.

July 15, 2018 – 44-year old Troy Allison dies after his attorneys alleged that he was given 1,000 micrograms of fentanyl.

September 30, 2018 – Bonnie Austin dies at Mount Carmel West Hospital after her attorneys allege she was given 600 micrograms of fentanyl less than an hour before midnight. Her medical records show the order was not reviewed by another physician, nurse or pharmacist.

October 24, 2018 – James Nickolas Timmons, 39, dies after receiving 1,000 micrograms of fentanyl.

October 25, 2018 – Mount Carmel West says it received a “formal report” concerning an allegation about Dr. Husel’s patient care.

October 25, 2018 to Nov. 21, 2018 – Three more patients die

November 21, 2018 – Dr. Husel is removed from patient care.

December 4, 2018 – Memo goes out to Mount Carmel staffers expressing concerns that some employees didn’t live up to the hospital’s standards of care.

December 5, 2018 – Dr. William Husel is fired.

December 13, 2018 – Additional memo goes out to Mount Carmel staff

December 27, 2018 – Mount Carmel begins notifying patient families

January 14, 2019 – WBNS-TV’s 10 Investigates breaks story of patient deaths. First wrongful death lawsuit is filed. Hospital’s CEO and President Ed Lamb releases first of two video statements. Reached by phone, Dr. William Husel declines to comment and refers questions to his attorneys.

January 15, 2019 – Centers for Medicare and Medicaid begins process to start site survey through the Ohio Department of Health.

January 18, 2019 – CMS receives a report of substantial allegation survey conducted by the Ohio Department of Health at Mount Carmel West. CMS determines that Mount Carmel West was not in compliance with Medicare standards involving pharmaceutical services. “We have determined that the deficiencies are so serious that they constitute an immediate threat to patient health and safety.”

January 24, 2019 - CMS receives a report of substantial allegation survey conducted by the Ohio Department of Health at Mount Carmel St. Ann’s. CMS determines that Mount Carmel West was not in compliance with Medicare standards involving pharmaceutical services. “We have determined that the deficiencies are so serious that they constitute an immediate threat to patient health and safety.”

January 24, 2019 – Mount Carmel releases updated statement announcing that the number of patients believed to have received potentially fatal doses of fentanyl has increased from 27 to 34.

The hospital also released this: “We received a formal report on October 25, 2018, that related to Dr. Husel’s care. Based on what we learned about that report, we should have begun a more expedited process to investigate and consider immediate removal of Dr. Husel from patient care at that time. Dr. Husel was removed from patient care on November 21, 2018. We are aware of three patients who died between October 25 and November 21 after receiving excessive and potentially fatal doses of medication ordered by Dr. Husel. We are sorry for this tragedy, and we will continue to investigate how we responded to this report and whether there is any other information that should have led us to investigate sooner into Dr. Husel’s practices.

“We are investigating whether Dr. Husel ordered excessive doses of medication when there was still opportunity to explore if there were reversible causes of patients’ immediate conditions.”

January 25, 2019 – State medical board announces that it is suspending the medical license of Dr. William Husel. The Ohio Department of Medicaid suspends the provider agreement with Dr. William Husel, accusing him of fraud for billing Medicaid for “medically unnecessary procedures involving grossly inappropriate doses of fentanyl.”

January 30, 2019 – CMS sends letter to Mount Carmel West notifying the hospital that its Medicare and Medicaid funding will be terminated unless they submit an acceptable plan of correction.

February 1, 2019 – CMS sends letter to Mount Carmel St. Ann’s notifying the hospital that its Medicare and Medicaid funding will be terminated unless they submit an acceptable plan of correction.

February 4, 2019 – Mount Carmel employee speaks out regarding the scandal to 10 Investigates. He alleges that Dr. Husel is responsible for ordering the high doses, but that the hospital’s lack of training of staff and lax internal controls led to a “systemic failure.”

February 5, 2019 – Correspondence between Dr. Husel and state medical board show that he apologized for his 1996 misdemeanor conviction for improperly storing a destructive device or pipe bomb while attending college in West Virginia. He also admits in a 2013 addendum to his medical license application that he got caught up in the wrong crowd, broke into cars and that his arrest more than 20 years ago is not reflective of the person he is today. Husel wrote: “my passion is taking care of sick patients in the ICU. Please give me the opportunity to practice what I love doing.”

February 5, 2019 – Mount Carmel acknowledges it has sent its plan of correction to CMS. Its federal funding hangs in the balance on whether CMS will accept its plan. Pharmacy manager Janet Whittey tells the state pharmacy board that she is no longer employed at Mount Carmel. The hospital has not said if she was fired or quit.

February 6, 2019 – Law firm identifies Melissa Penix as the patient who died on Nov. 20, 2018. The law firm of Leeseberg & Valentine alleges that Penix’s death may have triggered the hospital’s internal investigation. Three patients died between Oct. 25, 2018 – when the hospital said it received a formal report with concerns about Husel’s patient care and Nov. 21, 2018 – when the hospital removed Husel from patient care.

February 12, 2019 – The Centers for Medicare and Medicaid Services accepts plans of correction for Mount Carmel to fix its deficiencies. State health inspectors noted that Mount Carmel “failed to ensure that a system was in place to monitor and prevent large doses of medications” from being accessed via overrides from the hospital’s automated medication dispensing machines. Inspectors noted that inn 24 of the 27 patient cases it reviewed, Husel used an override to access the pain medications. The hospital announced it is changing policies – including capping doses of fentanyl and requiring that physicians and nurses get pharmacy approval before using medications during ventilator removals. Staffers were also being re-educated on what to look for and ask questions if they have concerns about dosing.

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