Local doctors ‘breached standard of care’ while treating elderly woman who died after discharge from hospital, judge rules

IDAHO FALLS — A Bonneville County judge has ruled four Idaho Falls doctors “breached the standard of care” while treating a 70-year-old woman, who died shortly after treatment.

But the question remains — did those breaches lead to her death?

District Judge Dane Watkins Jr. ruled on Feb. 2 that four local doctors, Kenneth Miller, Kevin Livingston, Jeffrey Hoffman, and Ryan Julian, breached the standard of care in multiple ways regarding their treatment of 70-year-old Gwen Tracy, who died shortly after being discharged from Eastern Idaho Regional Medical Center (EIRMC) in October 2019.

The cause of her death is currently unknown.

Watkins called the breaches “undisputed” and affirmed the doctors acted “recklessly and outrageously,” as testified to by witness depositions in November.

According to a news release from the Tracy family’s attorney, John Avondet, the physicians failed to investigate Gwen’s known health issues, leading to her wrongful death.

“The Court’s decision concerning the doctors’ breaches of the standard of care was well-reasoned and based on long-standing Idaho statutory and case law,” said Avondet. “The decision goes a long way toward obtaining justice for Ms. Tracy and ensuring physicians practicing in Bonneville County are held to accepted professional standards.”

Representatives from EIRMC and the office of the attorney for the four doctors, Greg Anjewierden, declined to provide a comment.

Background

Dana Tracy of Minnesota, Gwen Tracy’s daughter, filed a lawsuit on Oct. 1, 2021, against Eastern Idaho Medical Services, EIRMC, the Evangelical Lutheran Samaritan Society where her mother lived, and the four physicians stating the medical care provided to her mother was negligent, reckless, and “constituted direct, approximate causes of Gwen Tracy’s wrongful death.”

According to Avondet, Tracy’s attorney, the allegations against the Evangelical Lutheran Samaritan Society, Eastern Idaho Medical Services, and EIRMC were only filed to preserve the statue of limitations, and were later dismissed without prejudice.

The remaining case against the four physicians, accuses them of medical malpractice and wrongful death, negligence in hiring, training, and supervision, and negligent infliction of emotional distress.

Tracy argues the doctors failed to treat her mother with an acceptable level of care, dismissing her health concerns as dementia, when her delirium was allegedly actually caused by her other medical issues.

Court documents say Gwen was taken to the emergency room at EIRMC by her family on Oct. 8, 2019 for “complaints of confusion, weakness and multiple falls.”

According to Watkins ruling, Gwen was at EIRMC for eight days, in which she “gained weight, developed generalized edema, experienced increasing confusion, and required greater amounts of supplemental oxygen.”

When Gwen was admitted, Dr. Miller was responsible for “overseeing Gwen’s treatment throughout the duration of her stay at EIRMC.”

EIRMC records reportedly show Gwen had a known history of Chronic Obstructive Pulmonary Disease (COPD) with CO2 retention, electrolyte imbalances, a cardiac history of coronary artery disease, chronic kidney disease, hypertension, diabetes with neuropathy, panic attacks, obesity and thyroid cancer.

The complaint says Gwen’s breathing continued to get worse during her stay, causing her to have “decreased breath sounds, prolonged expiration phase, rhonchi (bubbling sounds heard while breathing), and wheezing.” Gwen also reportedly gained nearly 32 pounds while at the hospital.

According to court documents, Gwen’s need for a change in oxygen levels was not documented until six days into her hospital stay.

The physicians allegedly never “ordered a chest x-ray, CT, ABG, end title CO2 monitoring or other interventions to investigate the change in respiratory status, breath sounds, and oxygen supplementation requirements.”

Gwen was also reportedly known to have a CPAP machine at home to help with her COPD, but there is no record that she was ever offered one at EIRMC.

On Oct. 9, Tracy reportedly had an “assisted fall” while at EIRMC. According to the National Institutes of Health, an assisted fall is when “a staff member is present to ease the patient’s descent or break the fall.” Doctors were informed of the fall, and no injury was reported.

Gwen was discharged from EIRMC on Oct. 16.

After leaving EIRMC, Gwen was admitted to Good Samaritan Assisted Living, formerly the Evangelical Lutheran Samaritan Society. On intake, around 9:52 a.m., Good Samaritan reported she weighed 278 pounds, when her usual weight was between 230 and 240.

Nurses at Good Samaritan reportedly noted Gwen had “diminished bilateral upper lobe sounds, and bilateral lower lobe crackles in lungs, with shortness of breath on exertion.”

At 2:30 p.m., Gwen was found by Good Samaritan staff “on the floor with blue lips and in a comatose state” according to the complaint.

The complaint alleges “despite Good Samaritan having actual knowledge of Gwen Tracy’s history of falls, there is nothing in the Good Samaritan records about Gwen Tracy having a bed alarm in place and activated to alert the nursing staff to her attempts to exit the bed without assistance.”

The complaint also states there were no indications of the call light being within Gwen’s reach, or that her bed was low enough to minimize the risk of injury if she fell.

Gwen also had no oxygen on when she was found.

In Sept. 2022, Tracy’s daughter Dana filed a declaration from another doctor and expert for the case, Dr. Joseph Chiovaro M.D.

Chiovaro testified that each of the doctors failed to address Gwen’s hypoxia and hypercarbia, failed to evaluate and treat her heart failure, failed to evaluate and treat her delirium, and failed her by “inappropriately attributing her changed mental state to dementia.”

A jury trial is currently scheduled for April 2024 to determine if the failures of the doctors caused the death of Gwen.