A Los Angeles County coroner's report attributes the death of one patient, Robbie Toney, to complications from the placement of her breathing tube, which caused her lung to collapse. The coroner said the March 25 death of the woman, 61, was from a medical accident, not natural causes.
For four hours before her death, Toney had complained about pain where the tube had been inserted, county health officials said this week. They are investigating whether doctors and nurses at the county-owned hospital failed to recognize that the pain was a sign of trouble and whether the tube had been placed properly in the first place.
Toney's daughter, Marshon, said Tuesday that no one at the hospital had informed her of any potential problems with her mother's care. A King/Drew official simply asked if an autopsy could be performed, she said.
"I'm very startled and dumbfounded and overwhelmed now," she added.
Toney's death and those of the other two followed months of public assurances by county officials and King/Drew managers that employees had been rigorously retrained and new policies put in place to prevent breakdowns in care.
Yet the errors involved in the deaths mirror those that regulators, accreditors and even the outside consultants running the hospital have repeatedly cited in the last year.
In at least two of the cases, including Toney's, county health officials say it appears that doctor trainees did not receive appropriate oversight from more-senior physicians, as required. The hospital has often been faulted for failure to supervise doctors training to be specialists.
The county Board of Supervisors, which has drawn criticism for its timidity in tackling King/Drew's woes, discussed the deaths in closed session Tuesday but took no formal action.
Four supervisors — Zev Yaroslavsky, Gloria Molina, Don Knabe and Mike Antonovich — either declined to comment or did not return phone calls after the meeting.
Supervisor Yvonne Brathwaite-Burke, whose district includes King/Drew, said she did not know what effect the deaths would have on the hospital's future because it was being scrutinized so intensely.
"They're under the microscope," she said, "so anything certainly causes concerns."
According to the county's preliminary investigation, the recent incidents also included:
A critically ill man with AIDS who died March 27 after King/Drew staff inexplicably waited seven hours to transfer him from a medical ward to the intensive-care unit.
County Department of Health Services officials expressed concern in a memo to the supervisors late Monday that the appropriate staff was not attending the patient during the transfer, when he went into cardiac arrest and could not be revived.
A patient with liver disease, who died March 28 and may not have received the appropriate medication at the right times for low blood pressure. The memo also said an anesthesiologist did not respond to a Code Blue alert, as required.
Each of the three patients was seriously ill, and it is not clear how long they would have lived without the lapses, county officials said.
But in its memo, the health department said the care of all three patients "did not meet the community standard."
"We're all disappointed when we find another episode that is unexplainable, where errors in judgment and failure of supervision happen when we have really identified all the problems," said Dr. Thomas Garthwaite, health department director, in an interview.