Organ donation shows risk from local coroners

The story spread across the national media like wildfire, and it sounded like a real nightmare for health care risk managers: Two hospitals in Colorado were accused of harvesting a man’s organs before he was declared dead. The coroner actually ruled the death a homicide, saying the cause of death was "removal of his internal organs by an organ recovery team."

The only trouble with the story? The coroner’s conclusions were dead wrong, according to everyone involved except the coroner himself. The two hospitals were dragged through the mud as people wondered how they could make such a mistake, but the truth is that the hospitals appear to have done nothing wrong.

They’re paying for the inexperience and callous comments of the coroner, say hospital officials and an expert panel convened to review the case. Unfortunately, the problem befalling the hospitals may not be unique and could hit any rural health care provider, says Jan Ronzio, director of risk management and safety at St. Mary’s Hospital in Grand Junction.

"What we have here is a coroner who is a layperson and not following through on what he is supposed to do," Ronzio says. "This is not a unique situation in areas where you have a coroner who is an elected official, not a physician, with no oversight from anybody."

The risk manager’s nightmare began in early October when Mark Young, coroner for Montrose County in western Colorado, issued this statement: "The death of William Thaddeus Rardin, 31, has been ruled a homicide. The cause of death was removal of his internal organs by an organ recovery team."

Young went on to say that Montrose Memorial Hospital in Montrose and St. Mary’s did not follow accepted medical standards or meet state guidelines in determining that Rardin was brain dead after shooting himself in the head.

Rardin had been taken to Montrose Memorial on Sept. 26 and was declared brain dead. After consulting with the Donor Alliance of Denver, which coordinates organ donations in the area, Montrose Memorial transferred the patient to St. Mary’s Hospital, where his heart, liver, pancreas, and kidneys were transplanted into other patients.

When Young issued a statement to the media declaring the death a homicide, alleging that the hospitals did not perform proper tests to confirm brain death before proceeding with the organ harvest, he did not specify what tests he thought should have been performed. He issued contradictory statements about the hospitals’ intent, at one point, saying that he thought the harvest was done in good faith but also alleging that the hospitals may have avoided the proper tests to get around Donor Alliance rules that would have prevented that organization from paying for the helicopter transfer.

The coroner said criminal charges were possible.

Officials from both hospitals tell Healthcare Risk Management that there was nothing unusual about Rardin’s case and that the organ donation was handled routinely, adhering to all appropriate standards. Deborah Ashby, spokeswoman for St. Mary’s, says, "We don’t think there was anything out of the ordinary." She goes on to say that the hospital sees no need to change any procedures and that the only mistake was made by the coroner.

But that doesn’t mean that there is no lesson for risk managers. Ronzio, the St. Mary’s risk manager, says the case does highlight two potential problems for rural hospitals. The first is the potentially huge ramifications of an inexperienced coroner assessing your work, and the second involves the transport of patients to facilities with more qualified specialists to confirm brain death. Young’s suspicions apparently were fueled by the fact that Montrose Memorial performed some tests to determine brain death, but the physicians involved understood that St. Mary’s physicians would do more sophisticated tests to confirm brain death before proceeding.

Ronzio says that was accepted procedure, and a necessity when rural hospitals don’t have the ability to perform all the tests themselves before transfer. Ronzio says the hospital has solid policies and procedures for assessing brain death, and her review after Young’s charges showed they were followed.

"I did a crosswalk between those and the documentation, and we were stellar," she says. "The Joint Commission has already called and said they don’t consider this a sentinel event. They are not looking into this because they know it is ridiculous. I am doing a root-cause analysis later on, between the three entities, just to see where we might have done something different as far as transporting a patient."

Young did not return Healthcare Risk Management’s phone calls seeking comment. According to county officials, Young is a part-time coroner who makes his living as a paramedic. In his initial statement to the media, Young said he had consulted with Montrose County District Attorney Thomas Raynes, before declaring the death a homicide, but the district attorney issued a statement saying he had had only a brief, general conversation and did not concur with the coroner’s decision.

Young’s actions prompted the formation of a committee of 10 coroners, physicians, district attorneys, and organ donor specialists who studied medical records and the coroner’s conclusions. The committee’s report was scathing in its criticism of Young.

"There was no deviation from acceptable medical standards," Raynes announced. "There was no homicide by removal of organs."

The cause of death should be amended from homicide to suicide, the members urged. The committee determined that Young had reviewed only 10 of 220 pages in Rardin’s medical chart and noted Young’s admission that he had no prior training or experience in the declaration of brain death other than the research he did on the Internet while investigating this case.

The committee made these findings:

• "The actions of Mr. Young were based on a lack of information and an inappropriate understanding of the medical and legal issues involved. His actions were reckless when, despite ample and competent evidence to the contrary, he rendered the ruling and completed the death certificate indicating that this death was a homicide due to the removal of Mr. Rardin’s internal organs by an organ recovery team. It was also irresponsible for him to then release these findings to the media, without appropriate factual confirmation and determination."

• "These actions have served to undermine the public trust in the organ donation system, as well as the public trust in the health care, coroner, and criminal justice systems."

The committee’s report was firm in stating that all proper tests were performed to confirm brain death before proceeding with the organ harvest, with no deviation from accepted standards, but Young did not back down. He issued a statement soon after the committee’s, saying that he does not consider the matter put to rest and may have a neurosurgeon independently review the case.

Young has threatened to proceed with a coroner’s inquest, despite the committee’s findings.

"This has created havoc, and the one who’s really losing is the family," Ronzio says. "There also are worries that this will hurt the organ donation system, because we’ve heard of people threatening to take their names off the organ donation list because of this. That would be totally unnecessary, because incidents like this only happen in the movies."