Veteran dies after medication error at Asheville VA hospital
ASHEVILLE, NC (WBTV) - When Jason Powell went to the Asheville VA Medical Center in September 2012, he thought he had a bad case of the flu.
The 40-year-old father of three had recently moved to Asheville after finishing a career in the Army that spanned more than two decades.
He left the Army on terminal leave in July but his official retirement date was September 1, 2012.
Powell and his wife, Jennifer, made the trip to the VA hospital, less than a mile from their new house, before the moving truck had even arrived with their belongings.
More than the flu
What the Powells thought was a case of the flu turned out to be far more serious.
Doctors said Powell had diverticulitis and a small perforation in his bowel. Jason Powell was admitted to the hospital to treat the infection caused by the perforation.
Jennifer Powell said her husband settled in for a hospital stay while she went back to the family's new home to prepare for the moving truck expected to come the next day.
"He'd be home in, you know, five-to-seven days," she recalled thinking.
It was the next evening before Jennifer Powell was able to get to the hospital to see her husband. The moving truck had come, her house was now a maze of unpacked boxes. One of her husband's new co-workers came to the house to watch the kids while Jennifer went to see her husband.
When she arrived at the hospital that night, Jennifer Powell got news she wasn't expecting from a doctor who had been caring for her husband.
"She bowed her head down and then she looked at me and said, 'Mrs. Powell, I'm sorry to say but there's been an issue with your husband. He's in ICU,'" Jennifer Powell recalled.
Jason Powell had been rushed to the ICU after a nurse realized he had stopped breathing.
Questions about medication, monitoring
Doctors were unsure how long Jason Powell had been left without oxygen because he was not hooked up to any machines that would monitor his oxygen intake.
Powell had been placed on a non-critical floor to be treated for an infection. Even though his vital signs were not being monitored, he was still being prescribed a powerful narcotic known as Dilaudid.
Dilaudid works in a way similar to morphine but is given in smaller doses because it's much more powerful.
Jason Powell's medical records show he was prescribed 1mg of the powerful opiate every four hours but was given 4mg on two different occasions.
It was after he had been administered too much Dilaudid that he was found unresponsive and rushed to the ICU, where he later died.
Doctor discloses 'medication error'
Jennifer Powell had just come to the hospital with her children when they walked in to find a team of doctors and other medical staff working to keep her husband alive.
"I sat my kids down and told them something had happened with dad, we weren't sure what it was but we needed you to come to the hospital," she recalled. "There was a handful of people in the room trying to revive him. And I just walked in - I ran in the room and started hollering his name and begging him to wake up."
Ultimately, Jason Powell died on September 6, 2012; less than a week after officially retiring from the Army.
In the time immediately after her husband's death, Powell says the ICU attending doctor told her something that still haunts her today.
"He said, 'Mrs. Powell, I have to tell you, morally and ethically, I need you to know that there was an error in your husband's care. There was a medication error. Not just once but twice,'" Jennifer Powell recalled.
(Click the photo above to see the full image)
Dr. Carl Bazemore, who then oversaw the ICU but is now the Chief of Staff at the Asheville VAMC, wrote a similar note in Jason Powell's chart.
"It should be noted that it was brought to my attention by his primary hospitalist, Dr. McLaughlin, on the afternoon of 9/6/2012, the patient received Dilauded 4 mg IV at 0933 and at 1330 on 9/5/2012, instead of 1 mg that was ordered by Dr. McLaughlin. This was disclosed to the patient's wife and sister. It was also discussed with the Chief of Medicine, Dr. Morgenstern, neurologist, and it is uncertain what bearing this may have had in the patient's hospital course," Bazemore's note read.
VA denies wrongdoing amidst lawsuit
Despite the disclosure from the VA doctor the day her husband died, Jennifer Powell says the VA has never claimed responsibility for her husband's death.
Powell filed a medical malpractice lawsuit in federal court in 2013.
Bazemore, who disclosed the medication error to Powell the afternoon of her husband's death, deflected the error as the cause of Jason Powell's death in a deposition taken as part of the lawsuit.
In his deposition, Bazemore said he could not link the overdoses of Dilaudid to Powell's death because of the time that elapsed between the second 4 mg dose of Dilaudid and Powell's time of death.
"Again, the time course, had it been closer to the administration of the medication, I'd feel more certain. But seeing what we have here with the autopsy, I just can't say," Bazemore testified.
Instead, Bazemore relied on the autopsy's finding that Powell died of a heart attack. Jennifer Powell's attorney argued that the heart attack was caused by Jason Powell being administered four times the prescribed amount of a powerful narcotic two times in a four-hour span.
DOCUMENT: Click here to read the full deposition
"Can you say that there was absolutely no way, whatsoever, that Dilauded had an effect on Jason Powell as far as did it cause any part of his death," Jennifer Powell's attorney, James Epperson, asked Bazemore at the deposition.
"I can't say," Bazemore replied.
Powell's lawsuit settled out of court in 2015. As part of the settlement, the VA was able to avoid having to admit whether it was responsible for Jason Powell's death in court.
"Has the VA ever taken responsibility for what happened to your husband?" WBTV Investigates asked Jennifer Powell.
"Absolutely not," she said. "What goes through my mind is how many families before me and how many families after me?"
VA settles thousands of medical malpractice cases
A review of records made public by the US Department of Treasury shows the VA has paid out claims in nearly 2,500 medical malpractice cases over the past five years.
The Department of Treasury is responsible for paying the claims when the VA agrees to a settlement, like in Powell's case, or is found to be responsible at a trial.
Department of Treasury has paid 29 settlements in North and South Carolina since 2012, records show. The 29 payments, which include Jennifer Powell's settlement, totaled more than $9.3 million.
The number of medical malpractice payments balloons to 2,483 when you look at all malpractice payments made on the VA's behalf between 2012-2016. The total amounts to $554.19 million.
VA issues statement
A spokeswoman for the Asheville VAMC issued the following statement in response to a request for an interview for this story:
"We were sincerely saddened by the death of Veteran Jason Powell and continue to offer our sincerest condolences to his family and friends."
"We take concerns about care seriously, and, in some cases, conduct internal reviews to ensure we provide the highest quality of care and identify opportunities for improvement. Our goal is always to do right by our Veterans."
"In December 2013, the Estate of Jason Charles Powell and Jennifer Powell, as administrators of the Estate and individually, filed a lawsuit against the United States, with a settlement reached on Aug. 31, 2015."
"We strive to provide our veterans with the highest quality medical care, and routinely assess our policies, processes and procedures to strengthen our service to our patients, their families and communities. Our mission remains focused to providing exceptional health care our Veterans, earned through their service to our nation."
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