Media

Probe into 2 Deaths Ends at VA Hospital in Bultler, PA

Findings sealed; patients contracted staph infections

Friday, August 13, 2004

By Karen Kane, Pittsburgh Post-Gazette

A federal investigation of the circumstances surrounding the deaths of two patients at the Veterans Affairs Medical Center in Butler has been concluded, but officials won't comment on what their inquiry found. ..

Local officials of the medical center have declined to answer specific questions regarding their internal inquiry except to say that it had been concluded, that their patient protocols are in compliance with national health standards set by the U.S. Centers for Disease Control and Prevention and that the facility has stepped up screening procedures.

Butler County Veterans Services Director John Cyprian had requested the federal probe after complaints from two county families who said their loved ones died from complications of an antibiotic-resistant staph infection they believe was contracted at the Butler facility.

Albert Richard McKnight, 76, of Forward, died May 20, at the VA hospital after he contracted methicillin resistant staphylococcus aureus (MRSA.)

McKnight had been brought to the hospital in February after being treated at Butler Memorial for congestive heart failure. He was assigned to a room with a diabetic amputee who had MRSA. McKnight's family had asked that he be moved, but said the nurses advised them such a precaution was unnecessary.

According to the Centers for Disease Control and Prevention, staph bacteria are common causes of skin infections, most minor. But some infections can become life-threatening and difficult to treat due to the bacteria evolving into antibiotic-resistant.

After McKnight's death was publicized, Cyprian received a call from the family of 63-year-old John Stevenson of Butler who had died May 4 at Mercy Hospital. He had been a patient on the fourth floor at the Butler VA hospital, where McKnight had been a patient. His wife, Gertrude, believes he contracted MRSA at the VA hospital, though he had been a patient at other facilities, and that he died from MRSA complications.

After that second call, Cyprian asked for a federal investigation. ...

...Gertrude Stevenson said on Wednesday that she hasn't heard anything from any veterans officials but is expecting to meet at some point. She said a meeting had been set up at the Butler facility in June but when she appeared with her attorney, officials said the meeting would be rescheduled. "We're still waiting,'' she said. ...

...Meanwhile, Stevenson said she has heard of the Butler VA's improvements in screening procedures. "Who knows, maybe lives are being saved because of all this,'' she said. Post Gazette

Five pathologists slipped into the microscope lab at Martin Luther King Jr./Drew Medical Center, steeling themselves to act after months of deepening suspicion.

They'd seen enough. They were convinced that their newest colleague, Dr. Dennis G. Hooper, was making dangerous mistakes. And on this August afternoon in 2000, they were prepared to turn him in.

Dr. Brian Yee had caught the first hint of trouble in April. Rechecking a 27-year-old man's blood work, he noticed that Hooper, a pathologist with 16 years' experience, had missed signs of leukemia.

Over the summer of 2000, the pathologists believed, Hooper had misdiagnosed at least four other patients.

One was Virginia Jackson, 75, known as "Mama Jackson" to her adoring 117th Street neighbors. In early July, Hooper had said she was cancer-free — having failed to spot the malignant cells in her urine.

Six weeks later, another pathologist, Dr. Theresa Loya, found invasive bladder cancer in a subsequent biopsy. The cancer would eventually kill Jackson, a mother of 16 and grandmother of 39.

About the same time, Dr. Hezla Mohamed was asked to recheck another of Hooper's cases. Hooper had seen "no area of malignancy" in the swollen neck tissue of a 59-year-old man, medical records show. Mohamed suspected that it was thyroid cancer — a finding that an outside lab would later confirm.

At a certain point, "you start to wonder if the person knows what he's doing," said Mohamed, now pathology chairwoman at the Los Angeles County-owned hospital.

In the microscope lab that August day, Hooper's colleagues worked out the details of a warning letter to the hospital's chief medical officer and his associate.

The letter said Hooper, in his first six months on the job, had lost specimens and at times cut tissue so sloppily that he could not make an accurate diagnosis. It meticulously charted his alleged failings, listing each by case number, and cautioned that his work "puts all of us and the institution at risk for medical malpractice."

Soon afterward, Mohamed recalled, the pathologists met with the hospital's medical leaders, who said they would investigate the complaints and keep an eye on Hooper.

Further entreaties brought no response. Tension gave way to bitterness as the colleagues realized that this was the hospital's final answer: silence.

"Here you had five pathologists signing a letter listing cases and telling administration in no uncertain terms that this pathologist has competency problems, and there was no response," said Dr. Timothy Dutra, who signed the letter.

Worse than that, he said, the hospital's medical leaders later denied ever receiving the letter, "even though I know it was given to them on three separate occasions."

Hooper continued working, whipping slides through his microscope with a speed some colleagues considered irresponsible. The tall, paunchy pathologist, once eager for their friendship, kept more to himself now, listening to the music of Yanni on his headphones and saving his charm for their boss, Dr. Irene Gleason-Jordan.

Even when confronted with mistakes, some co-workers recall, Hooper seemed indifferent to the life-or-death importance of his job. Though pathologists rarely see patients in person, they issue crucial verdicts based on blood or tissue samples. Depending on a pathologist's report, patients can return home to a normal life, require surgery and other treatment, or face the reality that their lives are ending.

Six months after the pathologists sent their letter, Johnnie Mae Williams, then 40, went to the public hospital in Willowbrook, south of Watts, for a seemingly minor gynecological exam. Hooper determined that she had cancer of the uterine lining, and surgeons quickly gave her a radical hysterectomy, taking out all of her reproductive organs.

Hooper was wrong.

He had seen cancer — but it wasn't hers. His findings, it was later determined, were based on a slide from another patient, who had brain cancer. In his report, Hooper raised the possibility that the slide had somehow been mislabeled, but medical records show no evidence that he investigated where the slide came from.

When Mohamed examined Williams' excised organs 2 1/2 weeks after her surgery, she found no evidence of cancer, according to Williams' medical records.

A uterine-cancer expert said that what Hooper saw on the slides should have made him wary. The cancer that he diagnosed is uncommon in a woman of Williams' age, and one cell type necessary for Hooper's finding was absent, said Dr. Lora Hedrick Ellenson, a professor of pathology at Cornell University's medical school, who reviewed Williams' medical records for The Times.

"Everything about this case should have raised all kinds of red flags," Ellenson said.

Mohamed informed at least five other doctors at King/Drew, including several involved in Williams' care, that she did not have cancer, the records show.

But no one told Williams.

She did not learn of the misdiagnosis until more than two years later, when a Times reporter — unaware that she didn't know — sought her out for an interview.

After the operation, "I felt like I wasn't even going to be a full woman anymore," she said, her hands shaking.

The mother of three had wanted to have more children. But she'd taken solace in being a cancer survivor, and she'd been grateful to King/Drew. "Everyone kept calling it 'Killer King,' " she said. "I used to say, 'No, that hospital saved my life.' "

Hooper, 55, has repeatedly declined to discuss the case and others cited in this article.

His attorney, James Andrew Hinds Jr., wrote in a Nov. 5 letter to The Times that the criticisms of Hooper amounted to "innuendo" and were "without factual substantiation." In fact, he said, Hooper cleaned up "an administrative mess at the hospital." Hinds also indicated that the doctor was precluded from commenting because of patient confidentiality rules.

As much as they scrutinized Hooper's performance at King/Drew, his fellow pathologists knew little about his past. The same was true, apparently, of hospital officials.

Had they looked into it more closely, they might not have hired him in the first place.

An unseen cancer

When Roberta Nesbit got the results of her biopsy back from a San Diego lab in 1995, she had reason to celebrate.

The mole on her groin was benign, according to Hooper, who was filling in for another pathologist at the lab. She was cancer free.

Actually she wasn't. Over the next 15 months, the melanoma would grow underneath her skin, becoming a massive tumor. She had a second biopsy, which revealed not only that she did have cancer, but also that it had spread to her lymph nodes.

Nesbit sued Hooper and the lab for malpractice.

In court papers, the pathologist's own attorneys conceded that even a second-year medical trainee would have spotted the cancer in the mole. But Hooper, they said, was not at fault: He must have looked at a slide from another, healthy patient, mislabeled by a technician as Nesbit's.

Nesbit's attorney, who dismissed Hooper's defense as specious, negotiated a $450,000 settlement with the doctor in 1998.

Less than a year later, Nesbit was dead at 57.

"We're not talking about some trivial error here," said Nesbit's lawyer, Richard Binder. "We're talking about something that cost someone her life."

Hooper moved on. By late 1997, he was filling in at a Reno medical center operated by the U.S. Department of Veterans Affairs and tending to private medical laboratories he had opened in California, Nevada and Wyoming. (He eventually operated at least six, at various times.)

At the VA medical center, former co-workers remember him in rumpled khakis, singing along with Elvis recordings during autopsies or lamenting the ban on the diet drug combination fen-phen. He'd hurry through dissections and slides, then make phone calls related to his outside businesses, they say.

As at King/Drew, it wasn't long before the quality of his work came into question.

In May 1998, a surgeon discovered that Hooper had failed to notice one of two tumors in a section of colon she had taken out, according to VA documents that The Times obtained through the federal Freedom of Information Act. Another pathologist determined the growth to be cancerous.

After a second physician expressed worries, Hooper was found to have made at least two more serious errors, VA documents show.

Ultimately, hospital administrators opened an investigation and sent slides from 346 of Hooper's cases to the nationally renowned Armed Forces Institute of Pathology for a comprehensive review.

Of these cases, nearly a third contained mistakes. The institute found that Hooper had made major errors in 10 cases and minor errors in 104 more. Major errors typically require remedies such as chemotherapy or surgery.

According to a published study and two experts, the standard error rate for major mistakes by a general pathologist such as Hooper is less than 1% when all cases are reviewed.

Hooper's rate was nearly three times that.

His contract as a fill-in at the hospital was not renewed, VA officials said.

"I would not hire him ever" again, said Dr. Paul Jensen, former chief of pathology and laboratory medicine at the Reno facility. "Wouldn't even consider it."

But the VA kept Hooper's litany of mistakes to itself — never alerting the Nevada Board of Medical Examiners.

Dr. Thomas Barcia, the hospital chief of staff, said VA lawyers advised him that Hooper's errors fell within acceptable industry norms.

To this day, if another hospital called to inquire about Hooper, the VA would give him a clean reference, Barcia said, adding that "the data I have does not show he was a substandard pathologist."

In 1999, the year after the VA's investigation of Hooper, another arm of the federal government sanctioned him for lapses in his private Reno laboratory.

The Health Care Financing Administration determined that Hooper had falsely claimed the lab was accredited by the College of American Pathologists. In fact, he had never applied for such accreditation, government records say...