A Columbus, Ohio doctor and the Mount Carmel Health System are being sued for allegedly intentionally administering a lethal dose of fentanyl to a woman in late 2017.
The wrongful death suit was filed by the estate of Janet Kavanaugh, who died at Columbus’ Mount Carmel West Hospital on Dec. 11, 2017 at the age of 79.
According to the lawsuit, Doctor William Husel prescribed Kavanaugh an excessive amount of fentanyl for the purposes of hastening the termination of her life.
Fentanyl is a powerful opioid pain medication, approximately 100 times stronger than morphine. Kavanaugh was given 1,000 micrograms of fentanyl through an IV, causing her death within 18 minutes, according to the lawsuit.
Kavanaugh’s family said they learned of the fentanyl dosage more than a year after Kavanaugh’s death. A physician-administrator called the family and informed them of the fentanyl dose, according to the lawsuit.
A second call alleged at least 26 other patients were the victims of excessive doses.
Kavanaugh’s family said they were told the staff members involved in her care have been suspended from patient care.
The Franklin County Coroner’s Office said it is investigating the matter.
In early December 2018 Mt. Carmel and Trinity Health Systems notified this office and other appropriate authorities with regard to conduct by a medical employee. This office met with Doctors, executives and attorneys for the hospital and been in contact with other law enforcement and state regulatory agencies. Mt Camel and Trinity Health systems have been fully cooperative and responsive to lawful requests for additional information and documents. A thorough investigation is being conducted.At the present time this office is not able to answer questions until the investigation is completed.
Mount Carmel issued the following statement:
Mount Carmel recently reported to authorities, the results of an internal investigation regarding the care provided by a doctor who, until recently, worked with patients requiring intensive care.
During the five years he worked here, this doctor ordered significantly excessive and potentially fatal doses of pain medication for at least 27 patients who were near death.
These patients’ families had requested that all life-saving measures be stopped, yet the amount of medicine the doctor ordered was more than what was needed to provide comfort.
On behalf of Mount Carmel and Trinity Health, our parent organization, we apologize for this tragedy, and we’re truly sorry for the additional grief this may cause these families. Our team has contacted these families and will continue to answer their questions and concerns as best as we can.
Following our discovery, we addressed related patient safety issues. We removed this doctor from all patient care and terminated his employment. We reported this situation to the appropriate authorities, including law enforcement. We changed processes to help ensure this event does not happen again.
We’re working hard to learn all we can about these cases, and we removed 20 hospital staff from providing further patient care while we gather more facts. This includes a number of nurses who administered the medication and a number of staff pharmacists who were also involved in the related patient care.
Mount Carmel provides compassionate care that takes into account the decisions of patients and their families. We believe in helping patients who are near death die peacefully and naturally.
The actions instigated by this doctor were unacceptable and inconsistent with the values and practices of Mount Carmel, regardless of the reasons the actions were taken. We take responsibility for the fact that the processes in place were not sufficient to prevent these actions from happening. We’re doing everything to understand how this happened and what we need to do to ensure it never happens again. We’re joined in this effort by leaders of Trinity Health and we’ve asked outside experts to assist us.
Our integrated team is identifying immediate root causes to ensure that our best-practice care guidelines are followed. So far, these include a new escalation policy for increases in pain medication dosing and a new approval process for pain medication at high doses during similar situations.
For many years, Mount Carmel has worked to reduce medical errors and create a culture in which staff report concerns. In particular, over the past 18 months, we have engaged in ZeroHarm and High-Reliability training to stop preventable medical errors—work that puts systems into place to make the care we provide highly reliable and consistent. This focus on high-reliability helped us to discover these events because one of our employees spoke up and reported a safety concern.
Despite our meaningful progress in building a high-reliability organization, we recognize we have more work to do. We’re committed to making sure our employees work in an environment where they have the right to speak-up—without fear of retribution.
As with everything we do, we will continue to rely on our values to guide us in responding to these events. We will continue to do the right thing, to act with integrity and be transparent.
While these actions have brought shock and hurt to our organization, this will not define us.
Our more than 11,000 employees at Mount Carmel are outstanding professionals committed to safe, high-quality, people-centered care. Together, we will find strength in the values and beliefs we’re known for.
Our thoughts and prayers are with the involved patients and their families, and we ask for their forgiveness.
We will learn from this, and we will do better—because our patients and their families deserve our very best.