Lawsuit claims eastern Iowa hospital repeatedly shut off patients' oxygen, leading to one death
October 9, 2021
It had been a rough week, but David Hackley's family was looking forward to finally bringing him home.
Hackley, 77, was admitted on Jan. 2, 2020, to Gundersen Palmer Lutheran Hospital in West Union for pneumonia. A retired longtime West Union police chief, Hackley improved over the following week, and by Jan. 6, the hospital was making arrangements to discharge Hackley to a skilled nursing home for rehab before he was discharged to go home.
But early on the morning of Jan. 7, something went wrong. According to a lawsuit filed by Hackley's family, a nurse reportedly tried to wake Hackley just after 7:30 a.m. and wrote later he was "difficult to rouse, does not respond to verbal stimuli, slow response to painful stimuli/sternal rub, color grey/ashen."
The problem, Hackley's family alleges, is that at some point over that night, the oxygen machine feeding Hackley's nasal tube was shut off.
A healthy person usually has an oxygen saturation level of 95% or higher, and doctors had directed Hackley to be maintained at 90% or above, but by the time he was found that morning, Hackley's oxygen saturation was in the 50s, according to his daughter Dina Taylor, who was a nurse in the same facility at the time.
The lawsuit describes Hackley as being mentally disoriented and physically in pain after the prolonged oxygen deprivation, and within two days, he was dead.
In their lawsuit, Hackley's wife, children and estate accuse Palmer Lutheran and various employees of negligence and wrongful death in Hackley's case, which Taylor says has shaken the close-knit family to its core.
"We were expecting him to come home. That was the plan," Taylor said. "Anniversaries, birthdays, Father’s day — they’re hard."
La Crosse-based Gundersen Health System, which owns Palmer, did not immediately respond to a request for comment Friday.
Hackley's family say they want to see permanent changes in how Palmer operates and include claims in their lawsuit that a second patient at Palmer also was found with their oxygen deactivated after Hackley's death. Taylor says they want to see better training and processes at the hospital and more transparency and compassion in how it treats patients and families.
"We don’t want anyone else to experience this pain we’re going through — and the heartbreak and the loss of trust," she said.
Taylor says the family hasn't heard any explanation from Palmer. In their one meeting with hospital administration shortly after Hackley's death, they were told only that the incident remained under internal investigation. In fact, Taylor says, coworkers say they were told not to talk to her at all after her father died.
"It was like I was nonexistent," Taylor said. "... People were scared to talk to me or even look at me. Ever since that, it was like I was invisible. Nobody would look me in the eye, nobody would talk to me, nobody would smile at me in the hallway."
Taylor now works for a different health care provider and said she had to make the change for her own mental health.
"I would pull into that parking lot and just cry, knowing I had to face this again today," she said.
Attorney Ben Novotny, who is representing the family, said the system's lack of transparency is forcing the Hackleys to seek answers in court. The end goal, he said, is a stronger, safer local health care institution, and the complaint notes concrete improvements the hospital could make, including better monitoring and automatic alarms for patients receiving supplemental oxygen.
"The one thing (the family keeps asking) me over and over is, 'We’re not going to shut the health center down, are we?' They care about the brick and mortar and the hospital and people that work there," Novotny said. "They just truly want it to be better."
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