Waiting room death brings scrutiny of staff training, attitude

Seven hospital employees fired or suspended for failing to respond

A New York hospital is facing a $25 million lawsuit and reeling from devastating media coverage after staff failed to respond when a woman collapsed in the emergency department waiting room. Surveillance footage from a security camera was obtained by the media and played over and over again, showing the woman fall out of her chair, land face down, and then die as hospital staff just looked at her without offering aid.

The incident happened at Kings County Hospital in Brooklyn, NY. Video footage from June 19, 2008, shows 49-year-old Esmin Green, a mother of six, sitting in a waiting room in the hospital's psychiatric ED. She slides off the chair and lands face down on the floor, apparently convulsing. She had been involuntarily admitted June 18 for "agitation and psychosis," according to the hospital.

Green had been waiting nearly 24 hours for treatment, according to the New York Civil Liberties Union (NYCLU), which released the surveillance camera video of the incident. She collapsed at 5:32 a.m. June 19, the NYCLU said, and she stopped moving at 6:07 a.m. Workers at the hospital did nothing until 6:35 a.m., when the tape shows a hospital security guard approaching Green and nudging the woman with her foot but not immediately aiding her. Help was summoned three minutes later.

The hospital's parent organization released a statement saying seven people have been fired or suspended for their alleged involvement in the incident. They are the chief of psychiatry, chief of security, a doctor, two nurses, and two security guards, according to the New York City Health and Hospitals Corp., which oversees Kings County Hospital.

NYCLU also claims that hospital staff falsified Green's records to cover up the time Green went without assistance. "Contrary to what was recorded from four different angles by the hospital's video cameras, the patient's medical records say that at 6 a.m., she got up and went to the bathroom; and at 6:20 a.m., she was 'sitting quietly in waiting room' — more than 10 minutes since she last moved and 48 minutes after she fell to the floor," according to the NYCLU statement.

Systemic problems at hospital?

Similar incidents probably happen regularly in ED waiting rooms across the country but don't gain attention because the patient doesn't die, says Michael A. Mayers, CIC, CPCU, AAI, senior vice president, director of risk management services, and corporate risk manager for CBIZ, a consulting company based in Cleveland. The cause can often be traced to overworked ED staff, but Mayers points out that the Kings County Hospital surveillance video that looks so egregious to non-health care professionals might elicit more sympathy from hospital workers.

"All kinds of people end up in emergency waiting rooms, in various conditions, some of them just looking for a chair to sit in. The fact that someone falls isn't necessarily going to signal an emergency," he says. "The security person who came and looked at the woman probably had seen this a thousand times before, and it wasn't a medical emergency."

However, staff must be trained not to let their guard down and become complacent, Mayers says. Policy and procedures must dictate that patients are checked frequently, especially if there appears to be any change in their conditions, but he cautions that policies can always be overcome by human nature.

"If you're telling them to do that, to do it properly and stay alert, but then you're keeping them understaffed and overworked, you've created a situation where they cannot succeed," Mayers says.

While there is reason to sympathize with overworked ED staff, says Martin Kalish, MD, JD, a partner with the law firm of Arnstein & Lehr in Miami, who previously worked as a physician in several New York facilities, "there is something seriously wrong at the institution." He says he was particularly troubled by footage of the security guard who saw the woman but did nothing.

"To me, that tells me they have the wrong kind of security people working the psychiatric emergency room area," Kalish says. "You need people who are attuned to the kind of people in that area. These may be perfectly fine security guards in other areas, but they need to be trained and attuned to the kind of patient they will encounter in these psychiatric areas."

Kalish would advise the risk manager at the hospital to reassess orientation and training of staff, in addition to ensuring there are procedures in place for regularly checking on patients who are waiting. He also questions whether the patient underwent a medical evaluation while waiting for psychiatric care.

"Certainly a risk manager would want to take a look at the operation of the facility from top to bottom. How long does it take to evaluate a patient, and why does it take so long?" he says. "This is an unfortunate example of what can happen if you don't have the proper resources in place to minimize the wait and ongoing monitoring to make sure people don't get lost in the system. It sounds like no one was watching this patient as she got lost in the system."

Hospitals must have systems that prevent patients from being overlooked, says Jessica Roe, JD, an attorney with the law firm of Bernick & Lifson in Minneapolis. She recalls an incident in which a blind man went to a hospital ED seeking treatment and did not realize he was supposed to take a number and wait for it to be called. He was there for three hours before another patient realized the blind man never was called and sought help for him. Staff never noticed or made an effort to include him.

"We have to teach staff that it's not just about the procedures in place, not just the numbers," she says. "We have to help people retain some humanity and make sure patients are actually cared for and not just run through the system."

Roe says the Kings County Hospital incident points to a lack of proper staff training. The medical staff should have been trained to watch and monitor patients more closely, and security guards should have been trained to respond better when a patient appears to be in distress.

"Training is the first thing to be cut, because it's not a moneymaking endeavor," she says. "But this case shows just how shortsighted that can be. Not only is a patient dead, but the hospital is facing a real crisis now."


For more information on the incident at Kings County Hospital, contact:

  • Martin Kalish, MD, JD, Arnstein & Lehr, Miami. Telephone: (305) 357-3478.
  • Michael A. Mayers, CIC, CPCU, AAI, Senior Vice President, Director of Risk Management Services and Corporate Risk Manager, CBIZ, Cleveland. Telephone: (216) 447-9000.
  • Jessica Roe, JD, Bernick & Lifson, Minneapolis. Telephone: (612) 810-1807.