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Patient's questionable death doesn't make the list

A state health department director said Wednesday that David Croud's death was not included in the latest list of preventable "adverse health events" because the health department agreed with St. Mary's Medical Center that the hospital was not re...

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A state health department director said Wednesday that David Croud's death was not included in the latest list of preventable "adverse health events" because the health department agreed with St. Mary's Medical Center that the hospital was not responsible for his death.

The Minnesota Department of Health reports annually on 27 events that should never happen at a hospital, including death of a patient due to medication or use of restraints. Its most-recent report was released Wednesday.

Croud, 29, died on Oct. 18, 2005, six days after being taken to St. Mary's Medical Center after a combative arrest. The St. Louis County medical examiner ruled the death accidental, due to lack of oxygen from the brain from "acute alcohol intoxication and Haldol administration.''

Haldol is an anti-psychotic drug commonly used by hospitals and detoxification centers to help restrain patients agitated from drugs or alcohol.

In a report released by the state Health Department's Office of Health Facilities Complaints on Nov. 14, 2005, an investigator found that the way Croud was restrained contributed to his death.

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"Although interviews established that the police officers directed that the patient be positioned in a prone position, handcuffed behind his back on a gurney at the time of his admission, hospital staff did not adequately intervene to position the patient on his back or side; to request that his handcuffs be removed; and to request that four point cloth restraints be placed, at the time of admission or when the patient calmed down after he was medicated with Haldol, in accordance with acceptable standards of practice," investigator Pat FitzGibbons wrote.

FitzGibbons also reported that hospital employees did not reposition Croud until 44 minutes after his admission, even though Croud's position -- lying on his stomach, with his hands handcuffed behind his back -- put him at risk for breathing problems.

As for the Haldol, FitzGibbons said that it "could not be fully determined" that the dose given to Croud contributed to his death.

In a response added to FitzGibbons' report on Dec. 12, 2005, St. Mary's disagreed with the conclusion that the hospital contributed to Croud's death.

"The patient was not abused, neglected or harassed during the hospital stay. This patient presented with severely aggressive, combative behavior," the report said. "These hospital staff, and others, were all working to provide services in a safe setting for this patient, hospital staff and others."

Still, St. Mary's was required to enter Croud's death into the Minnesota Department of Health database as a possible adverse event, according to SMDC spokesperson Kim Kaiser. After an internal investigation, Kaiser said the hospital determined that Croud's death "was not attributable to any of the 27 preventable medical errors."

More specifically, according to Diane Rydrych, health department's assistant director of the division of health policy, the hospital determined that restraints did not lead to Croud's death, with which the health department later agreed.

While she said declined to talk specifically about why the department agreed with the hospital, she explained that any time a facility requests to have an adverse event pulled, health officials within the department convene to see if they agree with the facility's rationale.

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Kaiser said federal law prevents St. Mary's from commenting specifically on Croud. "However, it is important to note that a contributing factor is not the same as a preventable medical error," she said.

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