Investigation: Dangers of medical recovery rooms

February 4, 2013

Doctors told the parents of 17-year-old Mariah Edwards that their daughter was in the clear following a routine surgery to remove her tonsils.

But the next thing they knew, their only daughter was lying in a hospital bed lifeless and brain dead.

Mariah Edwards was a high school junior full of dreams and plans for the future.

"She could light up a room just walking though the door," her father said.

Three days after her 17th birthday in March of last year, Mariah walked into Abington Surgical Center in Willow Grove as a typical healthy teenager.

An outpatient tonsillectomy, that took less than an hour, was supposed to be the quick fix for her nagging sore throats.

"I said 'mommy loves you, I'll see you after your surgery,' and that was the last time I saw her alive," her mother, Angelique Mitchell, said.

The doctors initially reported to Angelique that her daughter's surgery was a success.

"I was told she was fine and she was going home and the next thing you know, she is brain dead," Mitchell said.

The once jubilant teen was rushed to the hospital, tied up to tubes, with no signs of life.

"How does this happen? How does this happen?" a tearful Mitchell said.

The parent's attorney Joel Feller uncovered the truth about what happened once Mariah was taken off the operating table and brought into the recovery room.

"She died as a result of being abandoned, not monitored, and not watched by nurses, in the recovery room for a period of over 25 minutes," Feller said.

The lawsuit claims Mariah laid there helpless after nurses administered a dose of the painkiller fentanyl.

"Fentanyl is a very potent narcotic, something like 50 to 80 times more potent than morphine," Feller said.

That drug, Feller says, threw Mariah into respiratory distress, but the nurse who was supposed to be watching her was busy tending to another patient.

"In a lot of respects, the recovery room is more dangerous than the operating room," Feller said.

In an operating room, a patient is being cared for by a team of nurses, doctors, and an anesthesiologist.

But in the recovery room, a single nurse is often left to attend to several patients who are coming out of anesthesia, administered powerful painkillers, and unable to communicate for themselves.

"You can only take care of one patient at a time," Dr. John Clark, Clinical Director of the Pennsylvania Patient Safety Authority, said.

Dr. Clark has found some of the greatest dangers in post-op are a result of improper monitoring.

In a shocking admission during discovery, a nurse at Abington Surgical Center in Willow Grove admitted the monitors attached to Mariah were muted.

"It was not just this monitor that was muted, all the monitors were muted for sound," the nurse said.

"If it is not providing that information then you are flying blind," Clark said.

The lawsuit claims Mariah laid there in respiratory distress with the curtains drawn, her brain literally starved by the lack of oxygen.

"When I got to the hospital, I never saw her eyes open or alive again," Mitchell said.

Abington Surgical Center did not want to go on camera, but the center sent a statement, saying in part:

"The Center changed several policies and procedures to assure incidents such as this do not happen again."

They no longer allow monitors to be muted, for curtains to be drawn, and they are requiring a one-to-one staffing of nurses and patients when the patient is given high powered narcotics.

But those procedures vary from center to center and hospital to hospital.

So it's important to ask about the recovery room plans before you go into surgery, what drugs will be administered, and who will be watching you.

The Abington Surgical Center sent this statement to Action News:

The events of March 20, 2012 that led to the death of Mariah Edwards were tragic. All of us at Abington Surgical Center extend our deepest sympathies for her loss to her family, loved ones and friends.

After the incident, the Center immediately launched a full investigation and reviewed all surgical and recovery policies and procedures. The Center engaged ECRI (a nonprofit organization that specializes in reviewing the safety of medical devices and procedures) and the Pennsylvania Patient Safety Authority to assist in these reviews.

The Center changed several policies and procedures as a result of these reviews to assure that incidents such as this do not happen again.

The Center, Abington Memorial Hospital and their attorneys believed that a legal settlement with Ms. Edwards' family was appropriate.

Abington Surgical Center has served area residents for over 23 years. We have safely treated more than 350,000 patients. The Center's mission is to provide the finest surgical care and we assure current and future patients and their families that we will continue to carry out that mission at the highest level of medical standards.

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