At 83, Martha Wright had never had a colonoscopy, even though government guidelines call for nearly everyone to be screened for colon cancer after age 50.
The Pleasant Hill resident was scared of the test, her daughter Dena Royal said, because she was petite — less than 5 feet tall.
“What she repeatedly said was, ‘I don’t want to have a colonoscopy; it will kill me,” said Royal, a former Kansas City paramedic and respiratory therapist. “We just kind of said, ‘Oh mom, it’s routine, it’s no big deal.’”
Wright had her first colonoscopy Aug. 2 at Cass Regional Medical Center, after a doctor recommended it because she was anemic.
She died the next day of internal bleeding.
It was a highly unusual outcome from a very common procedure that now has the Harrisonville hospital under extra scrutiny from government regulators.
State inspectors came out to investigate Wright’s death in late November after Royal filed a complaint. They found that Wright showed several signs of distress after the procedure, but Cass Regional staff didn’t properly respond. They also said 348 more colonoscopies had been performed there since Wright’s death, without addressing the deficiencies in care.
The inspectors passed their findings to the federal Centers for Medicare and Medicaid, which classified the situation as an “immediate jeopardy” that “placed all patients at the facility at risk.” It’s one of the agency’s most serious designations. If the situation is not promptly addressed, hospitals can lose their ability to bill Medicare.
Cass Regional CEO Chris Lang said via email that the hospital is complying with the feds’ guidance.
“Cass Regional Medical Center is aware of and has and is fully addressing the findings related to conditions/standards found to be in non-compliance during their visit, including the submission of a plan of correction to abate the IJ (immediate jeopardy) findings on 11/30/18,” Lang said.
The feds have reviewed and accepted Cass Regional’s plan of correction. But the hospital isn’t out of the woods until state health officials return for an unannounced re-inspection to make sure the plan has been properly implemented.
Meanwhile, Royal said she wants more answers about exactly what went wrong, but Cass Regional hasn’t turned over the results of an internal investigation. She’s hired an attorney who is preparing to sue.
“Something’s just not right here,” said Royal, who now lives in Washington state. “You don’t go in for a routine colonoscopy and then not come home.”
Lang said that once Royal hired a lawyer, the hospital was limited on the information it would release.
“As this is an ongoing legal matter, Cass Regional can not comment further,” Lang said. “All requests for documents associated with this matter are being handled through legal representatives, which has been communicated to Mrs. Royal.”
In a colonoscopy, patients are under general anesthesia while a doctor inserts a small flexible tube with a tiny camera through the patient’s rectum and into the large intestine. It’s a key tool for detecting colorectal cancers, but according to the Centers for Disease Control, about one-third of Americans who should be getting the test aren’t.
Still, it’s one of the most common medical procedures in the United States and it’s usually safe. Serious complications occur in only about 1.6 percent of patients, though experts say that’s still too high, given that millions of colonoscopies are done each year.
Deaths are even more rare.
In one of the largest studies done on the topic, researchers examined 16,318 colonoscopies performed in Kaiser Permanente hospitals between 1994 and 2002. They found only one death they could attribute to the procedure — a rate of 0.006 percent. A 2008 study on Canadian colonoscopy patients came up with a similar number.
By contrast, the five-year death rate for people with localized colorectal cancer is about 10 percent, and it spikes to almost 30 percent once the cancer spreads to surrounding tissues or organs.
According to the inspection report and medical records provided by Royal, Wright’s colonoscopy was, at least at first, the type everyone wants to get.
There was no sign of colon cancer. There were no polyps to be removed. It was a “clean” test that was “completed without difficulty or complications,” according to medical records reviewed by the inspectors.
Wright was sedated for the procedure, and because she didn’t have anyone to drive her home and watch her for 24 hours, she had to stay at the hospital overnight per Cass Regional’s policies.
The test was in the morning. By 5 p.m. she was complaining of pain in her left upper abdomen, but said it was tolerable: a 3 on a scale of 1 to 10. By 10:15 p.m. the pain had increased to 7 out of 10 and had spread to her left shoulder. According to medical records, a nurse told her she probably had gas and gave her Tylenol.
The inspection report said this is when nursing staff should have contacted the surgeon to inform him or her of the change in Wright’s condition.
Instead, the doctor wasn’t notified until about 2:30 a.m., when Wright awoke complaining of nausea, clammy skin and shortness of breath, in addition to the abdominal pain. The doctor ordered some tests, including a CT scan, but Wright kept getting sicker.
She was taken to the intensive care unit at 4:50 a.m., but by then she was unresponsive, with no breathing and no pulse. Hospital staff tried CPR, but at 5:14 a.m. Wright was declared dead.
The radiologist who read the CT scan found a “large amount of hemorrhage ... within the abdomen and pelvis,” which the emergency room physician listed as her official cause of death .
“She basically bled to death,” said Aaron Woods, the Lee’s Summit attorney Royal hired.
Royal said she knew something must be wrong when the phone rang early in the morning. But it was still a “gut-wrenching” shock to hear that her mother was dead.
“I mean, my mom was 83 but I thought she still had a lot of life left,” Royal said. “This was just so unexpected.”
Wright grew up in Kansas, Royal said. She moved to Missouri later in life, but she was a long-time member of Village Presbyterian Church in Prairie Village.
Other than the anemia, she was basically healthy.
Royal said even after the initial shock wore off, she struggled to accept her mom’s death, especially after reading the records of her final hours.
“That’s what’s so upsetting, that my mom had this slow tortuous death,” Royal said. “She was alert and telling them about the pain, but nobody seemed to take it seriously.”
Royal didn’t ask for an independent autopsy, a decision she said she now regrets.
But she said the surgeon who performed the colonoscopy told her the bleeding might have been caused by trauma to the spleen, a known risk of colonoscopies. The CT scan showed evidence of spleen damage.
It wasn’t the incident itself that drew the most concern from government officials, though. Medical mistakes happen. Cass Regional’s rate of re-admitting patients after a colonoscopy is 15.5 per 1,000. That is actually slightly better than the national average (16.4 per 1,000 patients), according to federal data.
What was most concerning to regulators was the hospital’s response. They said Cass Regional officials should have recognized Wright’s death as a “sentinel event” that signaled potentially broader problems, immediately investigated to find out how it happened and then educated staff about how to keep it from happening again.
Instead it was more than a month before the internal investigation started, and “the facility also failed to educate nursing staff in a timely manner,” the federal report said. When staff were eventually trained more on assessing patients’ conditions, it “was informal and without documentation of who attended.”
Cass Regional’s correction plan includes many policy changes to keep that from happening in the future.
Royal said she doesn’t want her mom’s story to prevent people from getting colonoscopies.
But she does hope it spurs people to closely monitor their loved ones’ medical care, even when it seems routine, and if something goes wrong, to report it to government officials. She said she was particularly impressed with the response of the Missouri Department of Health and Senior Services.
Royal said everyone at Cass Regional was kind to her, and she has no vendetta against the hospital. But she doesn’t want other people to go through what her mom did.
“It makes me realize,” Royal said, “that we all need to take a more active role in our health and the health of our loved ones.”