More than a decade after Kimberly Ray tweaked her back at her job, the pain was still bothering her. In early 2021, Ray’s provider at Integrity Wellness Center suggested a rhizotomy, in which the nerves responsible for the pain are severed or burned.
It’s a fairly routine procedure, typically considered low risk. And yet, while under general anesthesia, Kimberly stopped breathing. She never fully regained consciousness and passed away two days later at the hospital.
Laura Beil, who wrote about Ray’s story in a new investigation in Texas Monthly, joined the Standard with the details.
This transcript has been edited lightly for clarity:
Texas Standard: You write in your story there was a lot Kimberly Ray didn’t know about Integrity Wellness Center, and that wasn’t her fault. Tell us a little bit about what you found and what you mean by that, that it wasn’t her fault.
Laura Beil: Well, I think the point of the story is that it can be really difficult to know the history of the providers that you are entrusting with your life.
For example, the doctor who was on duty who came in to resuscitate Kimberly after her heart stopped. So I discovered that he had been dismissed from two different hospitals over concerns about patient safety. And yet if you look up his medical license, there’s nothing listed because it doesn’t appear that anyone ever reported him.
Or the CRNA who was taking care of her when she was under general anesthesia. He had also had a couple of incidents, kind of unexplained neurological symptoms was while he was on duty, slurring his words and having trouble walking. And she also didn’t know any of that.
You know, and if you take a wider lens at the clinic, most of the people working there were contract workers. They didn’t actually work for Integrity, at least the providers she had.
That’s something big here, because I think a lot of folks, you walk into a hospital, you think everyone works at the hospital. But as you point out, there are a lot of contract workers here.
Yes. I mean, we all kind of think if you walk into a hospital and you see someone in scrubs that they work for that hospital. But that may or may not be the case.
And I want to say that’s not an inherently bad thing. I mean, we have a health care provider shortage. And so through contract agencies, that’s one way that we can fill in the gaps is to have contract nurses, contract doctors. And so that in itself isn’t bad, and it’s a necessary part of health care.
But what I do have concerns about is when there are incidents, who’s accountable? And so, for example, in the case of the nurse anesthetist, after he had a couple of incidents at other hospitals, he was reported to the board by the contracting agencies.
But in the case of the physician who lasted less than a month when he was assigned to a hospital in Longview, it doesn’t appear that that anyone ever reported him. And I’m not sure why. But there’s maybe a demarcation of responsibility that that occurs.
» GET MORE NEWS FROM AROUND THE STATE: Sign up for Texas Standard’s weekly newsletters
And let’s zoom in a bit on that, because Kimberly’s story can be taken as an example of a concerning trend in Texas, right?
Yes. So the patient advocates I talked to have a great deal of concern that there is a disincentive to report people to the board because we have, through 20 years of reforms in malpractice cases, kind of rendered most malpractice cases really not worth the cost of going to court.
And so what patient advocates tell me is there’s not really a fear now, if you have substandard care, that a doctor is going to get sued. What they do fear is getting sued if you report them.
So, for example, if I were to report a doctor to the medical board, that doctor might sue me, saying, “you affected my ability to make a living by reporting me, and my livelihood.”
And therefore other doctors or administrators might have some pause before reporting someone. And so it’s much easier just to solve your problem by making it someone else’s problem.
Are there any lawmakers or organizations that you’re aware of working to address this issue, or no?
I did interview one patient safety advocate from an organization called Texas Watch … they’re a nonprofit and they focus on trying to make things better for patients, trying to improve patient safety. And they’re quite active. And that’s one that I’m aware of.
Did Kimberly’s family get any resolution after her death?
They did want to bring a civil suit and partly because they felt like she deserves some kind of justice. But I talked to her mother, who was very intent that Kimberly’s voice not be forgotten. And so one of the benefits to the public of a civil suit is you do create a public paper trail.
So in the case of Kimberly, all the records I was able to draw on were from the civil suit, which had been entered into the public record as part of the civil suit. So anybody, you know, you could go and look them up.
And so they wanted a record of it, so what happened to her would not be forgotten. And maybe some some good will come of it.
But a bigger part of this, of course, is that this undercuts trust in the medical system writ large, it seems to me. I mean, if you don’t have people that are being reported, if there are disincentives for that reporting.
And it seems to me that in a state where there’s so much concern about health care and health care coverage, it’s the last thing you want. And it’s hard to know how to fix that, how to untangle that.
It is. And of course, my purpose is not to scare anyone from getting health care that they need or be afraid of doctors or hospitals. In fact, the vast majority of doctors care about their patients and want to do right by their patients. So I don’t want to give the impression otherwise. I know a lot of doctors. I admire a lot of doctors.
The issue comes in is when there are those bad actors, how do we root them out? I think maybe the profession needs to do more to try to police itself if patients are not able to do it and if the accountability system no longer fears patients.
