I was working late last night when I got a call from an employee at Memorial Hospital who asked a simple question related to our editorial on Thursday. “What responsibility did Mr. Torres have in all of this?” he asked.
He was not defending the hospital’s actions and said he, as with others, felt horrible about what happened. And he said, by and large, he agreed with our editorial. But he felt the editorial left out a key part related to the actions of Torres. In short, what about his responsibility to take care of himself, to make wise choices and get the care he needed?
I told him that I don’t know enough about Torres’ personal situation to know whether he was capable of making good choices at that point in his life. Based on the facts, it’s certainly not clear that Torres was in a condition – either due to his poor health or his sobriety – to make ration decisions that night. But, overall, I told him he made a valid point. We’re all responsible for ourselves, and too often hospitals are the last line of defense in the poor decisions we make.
At the same time, when someone dies within steps of a hospital entrance, it’s evidence that something is breaking in our culture. Whether it’s the fault of the hospital, our health care system or ourselves, something is seriously broken.
Here’s our editorial from Thursday:
- Paul Gullixson
Published: Thursday, October 27,
PD Editorial: A tragedy at Memorial Hospital’s doorstep
Unraveling the circumstances of the death of Michael Torres just steps from Santa Rosa Memorial Hospital’s front door will be a long and painful process. Explaining them in a way that the family of the victim and the community at large will understand will take even longer.
It’s safe to say, Memorial isn’t there yet.
Hospital officials sought to explain on Monday through a letter to “Our Community” in which it described, to some degree, what happened and what efforts have been taken to ensure it doesn’t happen again.
“As an organization, we did not act as expeditiously as we could have to obtain ambulance assistance for Mr. Torres, who when first discovered on the outskirts of our grounds the morning of Sept. 20 was alive,” Memorial Hospital CEO Kevin Klockenga said in the letter. “We deeply regret that we did not immediately summon emergency responders on Mr. Torres’ behalf.”
Klockenga says there was a 25-minute delay between the time that the 49-year-old Torres was found to be in distress and the time he was provided emergency care. But the hospital still doesn’t know the reasons for Torres’ “dramatic decline” in health.
“As a result, it is too early to make any determination as to whether or not there was anything we could have done to prevent his death,” the letter states.
Maybe not. But the hospital’s letter raises many questions about what efforts were made to give him a fighting chance.
The trials of hospitals are well established. Many of the nation’s 50 million uninsured residents turn to hospitals only during a time of crisis, leaving emergency rooms to bear the greatest burden for a broken health care system. This case also illustrates the gaps in our systems for caring for the homeless, particularly those dealing with alcoholism.
Witnesses say Torres appeared to be intoxicated and possibly dealing with withdrawal when he was brought to Memorial by ambulance at 3:15¬p.m. on Sept. 19. He was treated and released four hours later, but apparently Torres never left the grounds.
Hospital officials are understandably focused on why it took 25 minutes for him to receive emergency care after he was found on the ground in a critical state the next morning. But significant questions also need to be answered about what happened during the 12 hours from the point he was discharged to when he was found in dire condition. Who saw him outside the hospital and what efforts, if any, were made to reach out to him if it was evident he needed help? Furthermore, what limitations — legal, financial or procedural — existed that prevented or discouraged hospital staff or security guards from taking action?
Memorial says it has already taken a number of steps including retraining hospital staff to ensure a nursing supervisor is alerted when anyone outside is suspected of being in potential distress. But, again, does this suggest that someone did try to communicate about Torres’ condition, but the word didn’t reach the right people?
There’s no debating that Memorial his been a leader for generations in meeting the region’s emergency health care needs. But it’s fair to say that in the case of Michael Torres, the hospital’s actions were less than heroic.
And its explanation of what happened is far from complete.