Q&A with Blythe Bernhard and Jeremy Kohler: Uncovering a teen's death and a troubled health system
Missouri has been making headlines this month because its citizens have voted to reject the new federal mandate for health insurance. Blythe Bernhard, a California Endowment Health Journalism Fellow, and Jeremy Kohler at the St. Louis Post-Dispatch have been exploring a much less-discussed, but perhaps more important, aspect of the health system: the lack of basic patient protections. They started their series "Who Protects the Patients?" in May with a great piece about a doctor with a string of patient complaints but a completely clean record with the state medical board. On Aug. 2, they followed with Girl, 16, dies during restraint at an already-troubled hospital, which I mined for reporting tips in last Friday's post. I reached them at their office in St. Louis. The interview has been edited for space and clarity.
Q: How did you come across Alexis' death?
Jeremy Kohler: It was by accident, if you can believe that. We got a tip that a surgeon at DePaul Health Center in St. Louis had taken out the wrong kidney from a patient in 2007, so we requested the 2567 reports (Medicare deficiency reports) on DePaul from the state department of health. We did not find any evidence that they had investigated the kidney surgery, but we found the death of this 16-year-old psychiatric patient.
Blythe Bernhard: Luckily, we had requested 2007, 2008 and 2009, just to cover our bases, because she died in 2009. If we hadn't cast a wide net, we would not have found out about her. In fact, the report on Alexis was 10 pages out of 300 on DePaul, and hers were the last 10 pages. And when we found Alexis' case, we also found that the hospital had previously been cited for problems in its psych unit. When we found those, we knew we wanted to move very quickly.
Q: Why quickly? She died in October, right? So no one was itching to do this story.
BB: Those 2567 forms are short on detail, so we had a lot to find out. We didn't know the victim's age, gender or name. We originally thought a boy had died. But we knew because the 2567 said the victim had come to the hospital from a children's home that he or she might be a ward of the state. So that gave us an entry into state Social Service records. We also knew that the nurses had been reported to the state nursing board. It said that in the hospital's plan of correction And literally the same week that we were looking at the nursing board records, one of the nurses had a complaint filed against their license. Once we got all the records together, we realized the story was much bigger than one nurse.
JK: We didn't rush it in. The state was extremely hard to deal with. We requested these reports for several hospitals. It took a month just to get the reports about DePaul. They ignored our requests for two or three other hospitals and then we got an email the day before we published this story saying, "Your request dating back to early March slipped through the cracks twice."
Q: What was the reason for the delay?
JK: They said there was confusion about what we really wanted.
BB: They actually did use the term "slipped through the cracks."And there aren't any regional offices for us to visit. Everything is in the capital three hours away.
Q: Why did you decide to focus on this death as the second part of your series?
BB: We knew it was a story and had to decide if it fit into the series. Ultimately, we decided it did fit into the series and how medical errors are so hard to find out about.
JK: A wrong site surgery is a sentinel event. A homicide is a sentinel event. And the lack of reporting is pretty much the same for both.
Q: Where did all those great details in the lead come from?
JK: From the 2567 report, the Children's Division investigation, the police reports, the hospital's internal investigation.
Q: How did you end up with that?
JK: The police department obtained that during its criminal investigation, and we requested it through the Missouri Sunshine Law. We also got the medical examiner's report, including the autopsy. And the state Board of Nursing report.
BB: This is good for other reporters to know. Jeremy successfully argued that the police department was not bound by the same disclosure rules as other agencies. Basically, HIPAA didn't apply to them.
JK: We didn't know at first that the police were involved. The first record we had was the 2567, and that didn't say anything about the police. We knocked on the door of the nurse who was cited by the nursing board, and she said she wouldn't talk. But we explained to her that she was the only nurse named, and that ticked her off. She said, "What did the police say?"That surprised us. We had already asked the police if there was a report on the death, and they had said no. So we went back to the police. The city manager actually apologized to us and said, "You gave us the date of the girl's death, but we have this filed under the date we got involved." Which is understandable. Then they quickly turned around their report. Beyond the actual police report, I argued that the Sunshine Law pertains to all records retained by the department, not just those generated by the department. Then they handed over more than 700 pages of records.
BB: One of the reasons we knew this was a story was how rare it is for a medical examiner to call the police in a hospital death. I had never dealt with that.
Q: Nor have I. That's what makes the Conrad Murray case so unusual. It takes someone like Michael Jackson to die before the coroner's are willing to make it a criminal case.
JK: I covered the police for several years before doing this investigation so I have lot of experience with the Sunshine Law. You don't normally hear me say something nice about the Missouri Sunshine Law. In this case I was very happy there was language in there that allowed us to get all records retained by the police department.
BB: The police had worked really hard in this case, interviewed 40 people and spent months on it.
Q: Do you think they wanted this to come out?
JK: I don't know if I would go that far. I do think they were a little embarrassed that the first time I called they said there are no records on this death. When I went to pick up the records, the acting chief came out and apologized.
Q: When did you go to the hospital with what you had found?
BB: We called them probably two weeks before publication and said we're looking into a wrong site surgery and the death of a teen-age psychiatric patient and want to talk with you. They said, "We don't want to say we have no comment. We will answer whatever we can." We set up an appointment to go to a hospital and interview them. The next day the PR person called and cancelled. They wanted to be sure that they weren't portrayed as stonewalling and yet they felt constricted. Ultimately, they did try to answer as best they believed they could, in general terms. We didn't want to portray them in an unfair light, either. We wanted to show exactly what they had to say.
Q: When did you go to Alexis' family?
BB: We got her name from the police report. First we went to the foster mother because she was named in the report. She was hard to reach. We went to her house a number of times, and she was hardly ever home. When we did finally reach her she was nervous about needing permission from the foster agency. We tried contacting other members of the family and then heard from their attorney that they didn't want to talk.
JK: The foster mother said she was under orders from the foster agency not to talk to us. So we called her case worker from her living room, and they said that the case is still private so no one should talk about it. We said, "Well, she died."
BB: We tried to appeal to the family members, saying that we knew so much about the circumstances of Alexis' death and would benefit from someone talking about how she was.
Q: So where did you get the photo of her?
BB: The photo actually didn't run with the story in the paper. We were contacted by a mentor of Alexis', sort of a big sister, after the story ran.
JK: The need for a photo actually led us to something else. We didn't have a photo and realized on Friday that maybe we should go to her grave and see if someone left a photo there. We found the cemetery where she was buried and went to the office and got directions to her burial site. There was no headstone. So we went with a picture of a tree where her burial site was supposed to be.
BB: We have been contacted by many people who want to contribute to buying her a headstone.
Q: I noticed you didn't have any named experts in the piece. But they clearly informed the way you wrote it.
BB: At first we said, "Let's find experts in psychiatric care and get them to weigh in." When we wrote it, though, we realized the story could stand alone and that people would understand that a 12-minute delay in starting CPR was serious. We did ask some people if it was basic protocol to check on someone when giving them a sedative. Is the first responder supposed to start CPR? The editors were great in letting the story tell itself without a lot of extra medical information getting in the way.
JK: We also did a lot of research on chemical restraints and physical restraints.
BB: And we did talk with the company who trains employees at this particular hospital. They said the restraint described in Alexis' case is not something taught in their class and (they) actually recommended against it.
Q: How did you find them?
BB: They call this hold that Alexis was in the "CPI hold" throughout these records. The hospital said it's the training system they use: the Crisis Prevention Institute in Wisconsin. There are so many terms like that in these reports, especially the 2567s, which are really clinical and not written for the general public.
Q: What has the reaction been like?
BB: There's been more reaction than I anticipated. I think people want to be empowered when they make their health care decisions. So there's a lot of gratitude and a hunger for more (information).
JK: There was no negative reaction to our story. We are really grateful that the national health journalists have picked it up, and it's gotten a lot of traffic. It was a much more dramatic story than the first one.