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This story has been updated.
“Your husband is
dead,” the doctor told Linda Carswell.
This was not
supposed to happen. Jerry Carswell had been admitted to Christus St. Catherine
Hospital in Katy, Texas, with kidney stones. The previous night, he’d been
walking around his room, talking about basketball and the upcoming presidential
election with his son, Jordan. The plan was for the 61-year-old to be
discharged that morning.
Instead, at about
5 a.m., a phlebotomist entered Jerry’s room to draw blood and found him lying
across the bottom of his bed, not breathing, mottled and blue, without a pulse.
Staffers performed CPR for 25 minutes to no avail. Carswell was pronounced dead
at 5:30 a.m. on Jan. 22, 2004.
Upon learning the
news, Linda and Jordan Carswell rushed to Jerry’s bedside. Lying there, sheets
and blankets folded halfway up his chest, he looked as if he could be dozing,
except for the tubes running out of his mouth — remnants of the failed resuscitation
effort. Linda shrieked and grabbed her husband’s cold hands, trying in vain to
stir him.
The on-call
doctor suggested that the Carswells authorize an autopsy, launching the family
on a traumatic journey that still isn’t over.
Clinical
autopsies, once commonplace in American hospitals, have become an increasing
rarity and are conducted in just 5 percent of hospital deaths. Grief-stricken
families like the Carswells desperately want the answers that an autopsy can
provide. But they often do not know their rights in dealing with either
coroners or medical examiners, who investigate
unnatural deaths, or health-care providers, who delve into natural ones.
For the last
year, ProPublica, PBS “Frontline” and NPR have examined flaws in the U.S.
system of death investigation, finding that mistakes in America’s morgues have
sometimes helped convict the innocent and allowed the guilty to go free.
The
Carswells’ experience illustrates a different kind of injustice. Their case
would play out in pathology labs, lawyers’ offices and courtrooms for more than
seven years. It led to a rare $2 millionfraud judgment against Christus St.
Catherine, which was found by a jury to have deceived Linda Carswell about
Jerry’s autopsy. It also led to state legislation designed to strengthen
families’ entitlement to comprehensive, independent postmortem reviews.
It has not,
however, led to closure or accountability. Thanks to an incomplete
autopsy, Jerry Carswell’s cause of death remains unknown. He also has not been
laid fully to rest. His heart, retained by the pathologist who conducted his
postmortem examination, sits in a refrigerated cabinet in a hospital lab to
this day.
None of the hospital employees involved in the Carswell
case would answer questions from ProPublica. In a written statement, hospital
officials said they provided good care to Carswell, and that his autopsy was
sufficient.
Linda Carswell,
an English teacher at one of Houston’s elite private schools, said her family’s
macabre saga has left her lonely and disillusioned. She’s had to navigate
complex establishments — medical and legal — while processing the
shocking loss of her husband. Measured and proper, with black hair streaked by
strands of white, she cannot seem to make peace with her loss.
Linda and Jerry,
a history teacher and track coach, had been married for 33 years, raising two
sons. She recalled how they would sit on the couch, her head on his chest,
listening to the thump-thump of his heart. She is determined to get it back.
“It’s not just a
piece of flesh,” Linda said. “Your heart stands for love. It stands for who a
person is.”
A call to the medical examiner
Jerry Carswell
had been a patient at Christus St. Catherine for two days before he died.
A scan performed
on admission showed that, in addition to kidney stones, he had a cancerous
tumor on one of his kidneys. It was in an early stage and not considered life-threatening, his hospital doctor said. At times, he was
given medication to treat intense pain. He was administered the narcotic
Demerol in the hours before his death, records show.
State law
required that the hospital report Carswell’s death to the county medical
examiner’s office because it was unexplained, unobserved and had occurred soon
after he had received medical care.
But it’s unclear
whether this step was taken. Hospital records show that the night administrator
made a minute-long phone call to the medical examiner’s office at 6:35 a.m.,
but the office later provided an affidavit saying it had no record of the
call.
It may not have
mattered. Medical examiners rarely investigate deaths at health-care
facilities, experts say. Often, their resources are already stretched by
homicides, suicides and other suspicious deaths. They are seldom inclined to
dig further if staffers at a medical facility ascribe a death to natural
causes.
In court
testimony, the night administrator at Christus St. Catherine said she had
reported hundreds of hospital deaths to the Harris County medical examiner’s
office and it had never taken a case.
As she sat with
her husband’s body, Linda Carswell was unaware of the hospital’s reporting
requirement, or that the medical examiner was supposed to assess his case. She
and Jordan said they noticed that no one at the hospital would answer questions
about how Jerry had died. They knew Jerry had been administered narcotics
during his stay, and wondered whether the drugs had played a role in his
death.
Linda said that
when she asked Patty Elam, a daytime charge nurse, to call the medical
examiner’s office to request an autopsy, Elam told her the office had already
turned down the case. Elam declined to comment for this story but said in court
testimony that she did not speak with Carswell about the call to the medical
examiner’s office. Linda did not press the matter further, a decision she came
to regret.
Autopsy leaves questions unanswered
With the medical
examiner out of reach, Linda Carswell was determined that Jerry’s death would
not go unexplained. According to both her and Jordan, she asked Barbara Lazor, a
Christus St. Catherine administrator, about whether a private autopsy could be
arranged.
Carswell said the
administrator told her a private autopsy could cost as much as $10,000. Lazor
offered to have the hospital provide an autopsy for free, but Carswell had
concerns about authorizing the procedure. She was uneasy about whether the
hospital was being entirely truthful with her about Jerry’s care.
Carswell said
Lazor assured her that the autopsy would be independent — performed by a
pathologist at a different hospital, St. Joseph Medical Center. Elam returned
with a consent form. Linda checked off the box requesting a “complete autopsy”
and signed her name.
Later, in court,
Lazor and Elam would deny ever speaking to the Carswells about anything related
to the autopsy. The hospital employees would not comment to ProPublica.
Pathologist
Jeffrey Terrel started the autopsy on Jan. 23, the day after Jerry died.
The scope of his
examination wasn’t what the Carswells had assumed it would be, however. Jordan
Carswell said he and his mother expected a “complete” autopsy to be exhaustive,
including whatever it took to determine the cause of death. Linda and Jordan
Carswell said they insisted to hospital officials that they must test Jerry’s
urine for drugs to see if they contributed to his death.
But Terrel
performed no toxicology tests on Jerry’s blood or urine. Terrel later testified
that Jerry’s medical records suggested that drugs could not have contributed to
his death, based on dosage levels and the time of administration.
According to
experts, Terrel’s approach was standard for a clinical autopsy. Even though the
Institute of Medicine has reported that medication errors affect an estimated
1.5 million patients per year, it is not typical to conduct toxicology tests as
part of clinical autopsies. They are routine in forensic autopsies.
Terrel testified
he had performed more than 1,000 autopsies since starting his career at St.
Joseph Medical Center in 1977 and had never determined that an overdose caused
a patient’s death. Further, he
testified that he had never classified a death as “accidental” because those
cases would be referred to the medical examiner, court records show.
In his
preliminary report, Terrel said he suspected a heart attack was the cause of
death, but his final autopsy report said there was no evidence of a heart
attack. In court, Terrel said he still thinks a heart attack is the most
medically probable explanation.
Terrel also
testified that the cause of death was natural, ruling out medical error.
As Terrel
performed Jerry Carswell’s postmortem exam, Linda came across some discomfiting
information. St. Joseph Medical Center was owned by the same
company that owned Christus St. Catherine, the hospital where Jerry died.
The pathology group that employed Terrel worked for both facilities, she
learned.
Carswell said
that if she had known that the hospitals were linked, she would have paid for a
private autopsy elsewhere. Six days after her husband’s death, she and Jordan
delivered a letter to the pathology lab at St. Joseph Medical Center,
requesting the preservation of tissue and fluid samples “following any
diagnosis that may be made.”
Terrel later
testified that he interpreted Carswell’s letter as a legal threat. He stopped
working on the case immediately, putting Jerry Carswell’s tissue samples and
specimen slides into a cabinet.
Jerry Carswell’s
admitting physician, urologist Paul Cook, filled out and signed the death
certificate. Cook listed several findings from Terrel’s final autopsy report as
causes of death: inflammation and
infection of the abdomen and stomach, as well as the cancerous kidney tumor. He
checked off “natural” for the manner of death.
Yet, during the
trial, he testified that Jerry Carswell hadn’t needed treatment for the stomach
or abdominal problems and that the prognosis for the kidney cancer was
good.
Cook did not
respond to a request to speak to ProPublica.
‘You have Mr. Carswell’s heart’
Linda Carswell
compares not knowing why her husband died to the way a soldier’s widow would
feel if her husband went to battle and never returned. It ate away at her
psyche. Hospital officials’ refusal to discuss the matter fanned her grief into
anger.
On June 7, 2005,
Carswell sued the hospital in Harris County District Court, alleging negligence and fraud. “It was
strictly for us to know what exactly had happened,” she said of the lawsuit.
The legal
proceedings went on for years. In October 2006, her attorney, Carl Shaw, took a
deposition from Terrel that led to a ghastly revelation. Shaw was attempting to
determine what evidence Terrel had retained from the case.
“Is there
anything more than the slides?” Shaw asked.
“Yes. The heart,”
Terrel replied.
Shaw was taken
aback. “You have Mr. Carswell’s heart,” he repeated.
“Yes,” Terrel
confirmed, “and there may be blocks of other tissue.”
Terrel went on to
say that he had not informed anyone of what he had done, including Linda
Carswell.
When Shaw told
Linda the pathologist had kept her husband’s heart, she collapsed into a chair
in her kitchen and wept.
Later, in trial
testimony, Terrel said he had misspoken in the deposition and that he had not
retained the entire heart.
Pathologists told
ProPublica that organs are typically returned or disposed of once tests
performed as part of an autopsy are complete. It’s inappropriate to retain them
for an extended period without the consent of the next of kin, said Dr. Victor
Weedn, an assistant medical examiner for the state of Maryland.
In March 2008, a
Harris County judge hit Christus Health, the company that owns Christus St.
Catherine, with a $250,000 fine for improperly keeping Jerry Carwell’s
heart tissue and running tests on it without his family’s permission, as well
as mishandling his blood serum. “They
were using Jerry’s heart against him,” Linda said. “I was just furious.”
The lawsuit
finally went to trial in August 2010. After 22 days of testimony, a jury
cleared hospital nurses of negligence but determined that Christus St.
Catherine officials had committed fraud when obtaining consent for the autopsy
from Linda Carswell. The jury awarded Linda Carswell $2 million, including $1
million in punitive damages.
The hospital has
appealed, arguing there is insufficient evidence that administrators misled
Linda Carswell or knowingly made false statements about the autopsy.
Despite the
jury’s multimillion-dollar affirmation, Linda Carswell remains angry that the
negligence claim failed. The case was difficult to argue without an autopsy
yielding a confirmed cause of death, said Mike O’Brien, the Carswells’ trial
attorney.
“Without the
autopsy, you’re hamstrung,” he said.
Autopsy reform in Jerry Carswell’s name
As the lawsuit
dragged on, Linda Carswell mulled over the events of that morning in the
hospital. She was not aware of the differences between forensic and hospital
autopsies. And when she looked up the law, she learned that the medical
examiner’s office was required to consider cases like Jerry’s. The realization
that she could have pushed for a forensic autopsy by the medical examiner’s
office caused her to roam the house at night, sleepless, wondering how she
could have been so ignorant about the law.
Carswell was
determined to ensure that other families were informed of their rights. She
discovered that health-care facilities used different autopsy consent forms,
some of which did not clearly set out families’ entitlement to independent
private or forensic autopsies. She called a family friend, Texas Rep. Bill
Callegari, and urged him to introduce legislation requiring doctors to use
standardized forms that would make a complex system easier to navigate.
Callegari could
identify with Carswell’s distress. Decades earlier, his brother, a 27-year-old
Air Force B-52 navigator, had been killed during a training mission in Wisconsin
under mysterious circumstances.
Callegari finally learned the cause of the accident after he was elected
in 2000. A stranger, recognizing his name, explained that the plane had
malfunctioned while testing some high-tech equipment.
The Carswell family
would never have a similar reprieve from the pain of not knowing. “What
happened in this case was atrocious,” Callegari said of Jerry Carswell’s death.
“You can feel the anguish. You want to know. Right is
right, and you have a right to know what happened.”
In September, the
Jerry Carswell Memorial Act, which Linda worked with Callegari to draft, went
into effect. It requires Texas hospitals to use a standardized autopsy consent
form that spells out families’ rights when a loved one dies in a
medical facility, including: the circumstances under which a medical examiner
is required to conduct an investigation; that, in cases not taken by a medical
examiner, survivors have a right to have an independent pathologist conduct a
clinical autopsy; that the family has a right to place special limitations on
the examination; and that the person giving consent for the autopsy controls
the release of the remains.
Had the law been
in place when Jerry died, Linda said, she is certain she would have the answers
she needs. “And most likely Jerry’s heart would not still be in a plastic
bucket at St. Joseph’s.”
The missing heart
In the years
since her late husband’s autopsy, Linda Carswell has repeatedly asked the
attorneys representing the hospitals and pathologist to return his heart.
The hospital
attorneys have refused, saying the heart could become relevant evidence in the
case of a retrial. The attorney for Terrel, the pathologist, said the heart was
no longer in the possession of Terrel, the pathology group or St. Joseph
Medical Center. Rather, it was owned by a different company
that has since taken over the hospital, the attorney said. In 2006,
Hospital Partners of America purchased St. Joseph, but the company went
bankrupt two years later. Carswell sent a letter to the bankruptcy trustee,
offering to buy back Jerry’s heart. It was an asset of little worth in the
bankruptcy, she told the trustee, but of great value to her family.
Linda recently
learned that St. Joseph Medical Center is under new ownership, but she’s not
giving up.
She has selected
a special urn where her husband’s heart can be laid to rest.
Update, May 24, 2016: The winding litigation related to the death of Linda Carswell’s husband led to a Texas Supreme Court opinion on Friday that unanimously ruled against the widow. The court determined that Carswell’s fraud allegation should have been included in her original malpractice claim, and because it was added more than two years after her husband’s death it exceeded the statute of limitations for the case, making it invalid.
