WatchSonoma Watch

Memorial death is evidence that something is breaking

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.

8 Responses to “Memorial death is evidence that something is breaking”

  1. Julie Alberigi says:

    It is odd the PD didn’t do a follow up after the autopsy…Mr. Torres was not intoxicated or under the influence of drugs he had pneumonia and other health ailments.

  2. Julie Alberigi says:

    It is odd the PD didn’t follow up on the autopsy results…Mr. Torres was not intoxicated and he was not on ay drugs…he had pneumonia and other ailments.

  3. LocalCTZN says:

    Isn’t someone given the medication Mr. Torez was given not supposed to be released without supervision? Wouldn’t even a jail been a better place? Ride “home” by police if no family members were able to be located etc? I have been misdiagnosed by Memorial in ER and granted it could happen to anyone by any DR. no matter how qualifed. What if the patient can’t speak up for themselves or as in my case were just not listened to??? Memorial has saved many lives including my own family members but the risk of the unknown, misdiagnosis, the evasive condition or just stuck on the wrong “diagnostic thinking” is always there and should we not judge our society by how we treat the weakest and the most unable to protect themselves? I ran into a son of a former instructor of mine who said they never let their parents stay in Memorial without someone there 24hrs a day to “watch over” them. Should this really be necessary? What does it say about our local medical system? I am educated and able to speak up for myself and after the last visit I haven’t gone back no matter what I needed because I wasn’t heard, didn’t get a care plan explained to me, was taken all over the hospital and was there till the next mid day and it turned out I had never been admitted??? How can you be put in a room on a floor upstairs and never admitted? What about explaining what the treatment plan is to either the patient or calling the family member? This sucked and it was frightening. I was even given injections for being in bed so long to not blood clots??? I had IV’s. But remember not admitted officially. To say the least I was tramatized where I was supposed to be assisted in recovering from a health condition. Not a drug or alcohol condition either. And yes I have insurance. And don’t you think everyone should get told what the medications they are being given are and what they are for and not have to ask???? How do you protect yourself from possible errors under such a situation? These are all issues that can be eliminated with communication and procedure guidelines.

  4. sarkyfish says:

    We are not our brother’s keepers. I know this is hard for control freak liberals to understand. Mr. Torres made his choice and died by the consequences. Give the man the respect he deserves. He was a human being; not a disease. His drinking was fun. Sure, he got addicted, but he knew that was possible when he took his first drink. Ask yourself, where you would rather be: with the self-anointed dullards at Occupy America, or with fellow drunks at a bar having a good laugh?

  5. Graeme Wellington says:

    Torres made many free choices in his life. Why is it always the responsibility of someone else to aid him in avoiding the consequences of those choices? And then again being blamed if they fail to successfully “help” him avoid the consequences of his free choices?

  6. Julie Alberigi says:

    There are millions of americans that have diseases because of the choices they made at some point in their lives. This doesn’t mean that they do not deserve to be treated when they are in dire need. Mr. Torres was discharged because the treating physician felt there was nothing more they could do for him. Although, he was given medication that would wear off in a few hours and he would likely end up right back in the hospital. Why? Maybe Mr. Torres was not in withdrawal, maybe he was severely ill from pneumonia, or maybe is was in the beginning stages of heart failure (heart attacks can go on for hours). Why didn’t the hospital call an emergency contact or the number on file for Mr. Torres? Especially, if they were concerned about where to discharge him. Why did security escort him from the building, does this mean he didn’t want to leave. Maybe Mr. Torres was trying to get help and no one listened.

    This ordeal is not about the choices one makes in their lifetime, it is about whether or not, we as a community, state, and country just want to leave our uninsured, unemployed, mentally ill, substance dependent, homeless, etc. to die in the street.

    You never know where life’s journey is going to take you. You see, Mr. Torres could be your son, daughter, father, mother, brother, sister, friend, extended family member or you. He was my brother-in-law.

    Julie Alberigi

  7. Steveguy says:

    Mockingbird nails it on the head. The County is more concerned about an Agenda than helping those that really need help.

    The Orenda Center was severely cut back, and the privates can’t seem to handle the chronically alcoholic/ addict. The court system can’t even handle them.

    They aren’t just bums, they are someone’s family member.

  8. MOCKINGBIRD says:

    It is horrible what happened to Mr Torres. Speaking from someone who has had many alcoholics and drug addicts in my family, negative things happen because of their addictions. Many a sleepless night I have had. Santa Rosa Memorial Hospital is where most of the emergencies go. They treat the homeless and the addicts all the time. I believe they do the best they can.

    What would be really nice is if an addict who wants to get clean can walk up to a policeman and ask for rehab and immediately get it. We just don’t have enough options in this county. This man could have been taken to a rehab once he was treated instead of being released. He could be evaluated there and when he was sober given the opportunity to stay. The county has eliminated so many options and contracted out to private facilities that just can’t manage the service needs.