By Brian Maass
A 64-year-old Westminster grandfather with epilepsy died after the University of Colorado Hospital left him unmonitored for more than an hour during a test in which they had taken him off nearly all of his medication.
The hospital is accepting responsibility for the lack of monitoring that apparently contributed to the death of Charles Gray, who had entered the facility in good condition, hoping to improve his health, only to end up dead four days later.
A CBS4 investigation found that Gray was left unattended in the hospital for 65 minutes in October, a gap his family believes led to his death.
“I have no doubts my dad would be here today if they monitored him the way they said they would,” said Teresa Napowsa, one of Gray’s three children.
‘He wanted to give’
Gray suffered epileptic seizures his entire life. They prevented him from driving, working or supporting his wife.
“He wanted to give, not receive,” said his younger brother, Steve.
Gray entered University Hospital’s Epilepsy Monitoring Unit on Oct. 15 so doctors could study his brain, learn more about what was causing his seizures and possibly operate on him at some point.
He was placed in a room with a video camera, and the live video feed went to a nearby monitoring station. Gray was one of eight patients being monitored.
The hospital assured Gray he would be cared for and observed round-the-clock. They gave him a form letter that said, “There will also be a neurodiagnostic technologist in the monitoring booth at all times to maintain the equipment and gather data.”
Steve Gray said his brother trusted the hospital.
“He was very confident this would go well, that he would be monitored 2 4/7, and he had given his full trust and laid himself open to that hospital.”
The round-the-clock monitoring was crucial because doctors weaned Gray off his epilepsy medications to intentionally induce seizures so they could better understand what was causing his medical problems.
“An epileptic, when in seizure mode, needs someone with them,” Napowsa said. “And we all had complete trust in the hospital that they were going to care for him and watch him.”
But on the fourth night of his stay, hospital records show the technologist who had been monitoring the video feed from Gray’s room left the post at 11:50 p.m. to get something to eat and check on two other patients. Twenty-eight minutes later, Gray, who had been asleep, suffered one of the seizures doctors were trying to induce.
But there was no one watching, no one there to help. Hospital videotape of Gray provided to CBS4 shows the seizure caused Gray’s face to press into his pillow, apparently cutting off his oxygen supply. He stopped breathing a few minutes later.
According to hospital records, it would be another 37 minutes before the technologist returned to find Charles Gray unresponsive.
Efforts to resuscitate him were unsuccessful. The Adams County coroner listed his cause of death as “seizure.”
The hospital says its protocol at the time allowed staff members to leave the monitoring station unattended for short periods to check on other patients, get food or take a break.
Gray’s family was stunned to learn he was not being monitored round-the-clock, as the hospital had promised.
Hospital makes changes
“My family put their trust and faith in University Hospital to deliver what they said they would, and they chose not to,” Steve Gray said. “They chose not to deliver on the promises they made to my brother to ensure his health and safety through this process.”
The families’ lawyer, Kyle Bachus, said the hospital’s protocol defied logic.
“Common sense would tell you if you are going to take them off meds and you’re going to cause severe seizures to occur, somebody has to be there to help.”
About 3,000 patients have been through the epilepsy monitoring program without serious incident during the past 20 years, according to Dr. Steven Ringel, of University Hospital.
He said the hospital was “troubled by this” and has made changes “to increase safety of the hospital so something like this never happens again.”
‘He didn’t die in vain’
Ringel said the monitoring station is now constantly staffed. If a technologist needs to leave, someone else takes over so patients are always being watched.
Ringel said there will no longer be any gaps in monitoring of patients in the epilepsy unit. Additionally, he said a system has been implemented so that if a patient’s breathing decreases, an alarm goes off, summoning help. “He didn’t die in vain,” Ringel said. “We’re going to make changes to prevent this from happening to someone else.”
Ringel acknowledged that if someone had been monitoring Gray on the morning of his death, there was a “greater likelihood” he would have survived the seizure. “We do feel responsible for it,” he said.
Gray’s family is considering suing the hospital, but since University Hospital is a government facility it’s covered by the Colorado Government Immunity Act and the most it could be held liable for is $150,000. Family members say this isn’t about money but about holding the hospital accountable for its actions.
“It doesn’t seem fair,” said Napowsa. “It doesn’t seem right.”
Originally published by Brian Maass, CBS4 News, Special to the Rocky.
(c) 2008 Rocky Mountain News. Provided by ProQuest Information and Learning. All rights Reserved.
Comments