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Author Topic: 9-1-1 tapes indicate delayed response in woman’s death  (Read 5465 times)
okarol
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« on: October 24, 2007, 12:05:16 AM »

9-1-1 tapes indicate delayed response in woman’s death

01:00 AM EDT on Wednesday, October 24, 2007

By John Castellucci
Journal Staff Writer

PAWTUCKET — Recordings of the 9-1-1 calls made while Maria G. Carvalho was bleeding to death in her home on Gooding Street show that fire dispatchers failed to send an ambulance even though they were told she was losing blood.

The calls, which were routed by state 9-1-1 operators to the Pawtucket Fire Department’s dispatch center, begin at 10:57 a.m. Sept. 20, when Yvette LeBlanc, an 81-year-old neighbor of the Carvalhos, tells the dispatchers that Maria’s husband João has just come across the street and asked her to telephone them for help.

The calls end at 11:17 a.m., after one of the Fire Department rescue workers who was finally sent to 101 Gooding St. calls to tell the dispatcher to send the police.

By then, Mrs. Carvalho, a 53-year-old kidney patient, is dead, having lost an enormous amount of blood through the shunt inserted in her arm so she could undergo dialysis.

The attorney general’s office ruled on Oct. 12 that the failure to send an ambulance didn’t rise to the level of criminal misconduct, basing its finding on the determination of Assistant Medical Examiner Dr. Peter A. Gillespie that it isn’t possible to establish that the 15-minute delay caused Mrs. Carvalho’s death.

But Mrs. Carvalho’s family has placed the city on notice that it intends to take legal action, and the 9-1-1 recordings are expected to provide crucial evidence in the case.

The Pawtucket city solicitor’s office released recordings of the 9-1-1 calls yesterday, having withheld the recordings while the attorney general’s office conducted its investigation.

The recordings show that it was only at 11:11 a.m. — after the state 9-1-1 operator tells the Pawtucket Fire dispatchers that João Carvalho has called demanding to know why they haven’t sent a rescue truck — that one is finally dispatched.

Sean P. Mooney and Christopher A. Jeffrey, the dispatchers who were on duty at the time, have been fired. Both had less than a year on the job.

In an interview yesterday, Fire Chief Timothy P. McLaughlin called them “good kids. Unfortunately, they really made a really bad mistake,” he said.

Stephen M. Rappoport, the lawyer for the Carvalho family, said the rescue truck should have been sent as soon as the dispatchers heard that Mrs. Carvalho was bleeding.

Instead, they let LeBlanc talk about how Mrs. Carvalho was picked up every day by private ambulance for dialysis treatment, then told her the Carvalhos have to call for the rescue truck themselves.

“It went on and on and on. It was a farce,” Rappoport said.

LeBlanc’s call was initially to 9-1-1. Rappoport said it was immediately put through to the fire dispatchers.

“Well, and, a, he said they have a lot of blood, you know, like under her arm or something and on the floor,” LeBlanc tells the dispatchers. “So, I said, well what can I do? You should have called 9-1-1 instead of coming over here, you know.”

One of the dispatcher replies, “Um hmm,” and LeBlanc says João Carvalho has just gone back across the street. “He’s got a sore foot and he’s on his crutches,” she says.

“So where is he right now?” the dispatcher asks.

“He’s at — I guess [he] went back across the street. I mean, I said you shouldn’t have left Maria all alone. So anyway the front door is shut so he must be in the house.”

“A yellow house,” she adds. “right across the street from mine.”

There is some confusion. One of the dispatchers asks whether it’s João Carvalho who needs to go to the hospital.

“Not him, but her,” LeBlanc answers. “He’s on crutches and she needs to go on dialysis every day.”

“So why did he not call?” the dispatcher asks. “We can’t take against [inaudible] his will, or her will,” he adds. “You know, they would have to call.”

LeBlanc’s call lasts about 2 minutes. The state 9-1-1 operator calls Pawtucket about 10 minutes later.

By then, João Carvalho has called 9-1-1. “Something about, he called a half-hour ago and you guys haven’t got there yet,” the 9-1-1 operator says.

The dispatcher indicates he’s aware of the problem. “Bleeding from a dialysis site?” he asks the 9-1-1 operator.

“I don’t know,” the 9-1-1 operator answers. “That’s all he said over the phone. He was pretty outraged.”

jcastell@projo.com

http://www.projo.com/news/content/NO_PAWTUCKET_9-1-1_CALLS_10-24-07_J97JKQR.326e6ca.html
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Admin for IHateDialysis 2008 - 2014, retired.
Jenna is our daughter, bad bladder damaged her kidneys.
Was on in-center hemodialysis 2003-2007.
7 yr transplant lost due to rejection.
She did PD Sept. 2013 - July 2017
Found a swap living donor using social media, friends, family.
New kidney in a paired donation swap July 26, 2017.
Her story ---> https://www.facebook.com/WantedKidneyDonor
Please watch her video: http://youtu.be/D9ZuVJ_s80Y
Living Donors Rock! http://www.livingdonorsonline.org -
News video: http://www.youtube.com/watch?v=J-7KvgQDWpU
goofynina
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« Reply #1 on: October 24, 2007, 07:11:06 PM »

 :banghead;  WTF?  OH man, oh man, i sure hope this guy has some good lawyers and gets what he deserves for their stupidity.  :thumbdown;
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« Reply #2 on: October 24, 2007, 09:12:52 PM »

OMG!  Idiots!  >:(  >:(  >:(  Even if the family doesn't get a dime the two idiots need to sit in court and listen to how they let a woman bleed to death.  My heart aches for her poor husband.  :'(
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Lorelle

Husband Mike Diagnosed with PKD Fall of 2004
Fistula Surgery  1/06
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Creatinine 6.9  1/07
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« Reply #3 on: October 25, 2007, 09:28:31 AM »

Unfreakinbelievable! Some people are so stupid! I sure hope they sue the pants off those people!
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Diagnosed type 1 diabetic at age 6, CKD (stage 3) diagnosed at 28 after hospital error a year before, started dialysis February '09. Listed for kidney/pancreas transplant at Ohio State & Univ. of Cincinnati.
okarol
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« Reply #4 on: December 07, 2007, 09:55:26 AM »

Fired dispatchers ask for jobs back

December 7, 2007

PAWTUCKET, R.I.—Two fire department dispatchers fired after a woman bled to death while waiting for an ambulance have asked to be reinstated to their jobs.

Pawtucket dispatchers Sean Mooney and Christopher Jeffrey were fired in late September, after Maria Carvalho died when she began bleeding through a shunt used for dialysis.

Her husband spoke limited English and ran to a neighbor's house to call 911. But emergency recordings show they refused to send help, saying the call had to come from Carvalho's own house.

They sent an ambulance nearly 15 minutes later, after Carvalho's husband called 911 again.

Prosecutors said it was impossible to determine if the delay caused Carvalho's death, and did not bring charges.

The firefighters union has filed a grievance seeking to give the men their jobs back.

------

Information from: The Times, http://www.pawtuckettimes.com
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Admin for IHateDialysis 2008 - 2014, retired.
Jenna is our daughter, bad bladder damaged her kidneys.
Was on in-center hemodialysis 2003-2007.
7 yr transplant lost due to rejection.
She did PD Sept. 2013 - July 2017
Found a swap living donor using social media, friends, family.
New kidney in a paired donation swap July 26, 2017.
Her story ---> https://www.facebook.com/WantedKidneyDonor
Please watch her video: http://youtu.be/D9ZuVJ_s80Y
Living Donors Rock! http://www.livingdonorsonline.org -
News video: http://www.youtube.com/watch?v=J-7KvgQDWpU
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« Reply #5 on: December 07, 2007, 11:23:25 AM »

Oh crap!  They should NOT get their jobs back.  Thanks for the update, Karol.

Maybe we can get an email addy for the local paper and bury them with emails from all over the world?
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Lorelle

Husband Mike Diagnosed with PKD Fall of 2004
Fistula Surgery  1/06
Fistula Revision  11/06
Creatinine 6.9  1/07
Started diaysis 2/5/07 on NxStage
okarol
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« Reply #6 on: December 07, 2007, 11:39:00 AM »

Here's a more complete story from the Pawtucket Times:

 Fired dispatchers want jobs back 
on 07-12-2007 00:25 

By DONNA KENNY KIRWAN
 

PAWTUCKET -- Two Fire Department dispatchers are seeking reinstatement after being fired for their actions on the day a woman bled to death waiting for an ambulance. At least one is confirmed to be seeking back pay.

 
Firefighters Sean P. Mooney and Christopher A. Jeffrey were dismissed by the city shortly after the Sept. 20 death of 53-year-old Maria G. Carvalho of Gooding Street. Members of Carvalho’s family, through attorney Stephen M. Rappoport, have indicated their intent to sue the city, claiming the fired dispatchers were negligent.

In October, the attorney general’s office decided not to pursue criminal charges against Mooney and Jeffrey. Their ruling was based largely on Carvalho’s health at the time of her death.

Fire Dept. Lt. Robert Neill, president of the Pawtucket firefighters union, confirmed recently that the union has filed a grievance on behalf of the two former dispatchers, Sean P. Mooney and Christopher A. Jeffrey, to reinstate them.

City Solicitor Margaret Lynch-Gadaleta said the city has in turn filed a motion in Superior Court to stay the grievance, on the grounds that the two dispatchers, both rookies, are not entitled to union representation. She said the city’s position is that both Mooney and Jeffrey, who had both served on the Fire Department less than a year, were still on probationary status and are thus not entitled to the union’s legal support.

Lynch-Gadaleta said that, in the eyes of the city, “they’ve been terminated. It’s in the Department of Health’s hands now.” She was referring to a separate administrative review of Mooney and Jeffrey’s emergency medical technician (EMT) licenses that is currently underway by the DOH.

Bruce McIntyre, DOH deputy chief legal counsel, acknowledged that an advisory board has been reviewing the Carvalho case and the actions taken by Mooney and Jeffrey that pertain to licensing. He said that while the review panel is still having “earnest discussions” about the matter, the consensus is that the dispatchers’ actions should not result in the loss of their licenses.

While pointing out that the review is ongoing, McIntyre said the basic “threshold” question being asked by the DOH panel is whether Mooney and Jeffrey’s actions in their capacity as EMTs on that day make them a “danger to the public.”

“The answer to that is ‘no,’” said McIntyre. He said that a “mistake” was made, but according to applicable standards, their ongoing service would not represent a public safety hazard.

McIntyre said Mooney and Jeffrey are entitled to an administrative hearing, which he expects will be held shortly. “We’re still receiving information and collecting data, from the city, from the licensees and others who were involved. We’re trying to get this right,” he stated. In the meantime, both Mooney and Jeffrey remain actively licensed as EMTs.

As to the pair’s short tenure, McIntyre said the entire work environment and training issue comes into play. He referred to an EMT’s job as one that involves “ a lot of moving parts” and said “it could mean there is a problem with one of the moving parts.”

“We’re still trying to unravel things,” McIntyre said.

Neill, in his capacity as union president, said the union disputes the city’s assertion that Mooney and Jeffrey are not entitled to union representation. Given that the two men have been paying union dues from the time they started their respective jobs, “we feel they have the benefits afforded them by the union,” Neill said. He expects that a neutral arbitrator will be chosen to hear the case, a process that could take several months.

Both Mooney and Jeffrey have also retained private legal counsel. Daniel McKinnon, a Pawtucket attorney representing Sean Mooney, said he has filed a motion allowing him to “intervene” in Mooney’s behalf in the grievance proceedings.

McKinnon said Mooney is seeking to be reinstated as a dispatcher and to collect back pay from the time he was fired. He said his claim does not address the issue of criminal wrongdoing, which his client was cleared of, but is instead “strictly contractual.” McKinnon maintains that his client “did nothing wrong. He did that which he was taught to do.”

Jeffrey’s attorney, Stephen Reid, declined to comment in detail, citing his usual practice when a case is in arbitration and litigation.

http://www.pawtuckettimes.com/index.php?option=com_content&task=view&id=3210&Itemid=27



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Admin for IHateDialysis 2008 - 2014, retired.
Jenna is our daughter, bad bladder damaged her kidneys.
Was on in-center hemodialysis 2003-2007.
7 yr transplant lost due to rejection.
She did PD Sept. 2013 - July 2017
Found a swap living donor using social media, friends, family.
New kidney in a paired donation swap July 26, 2017.
Her story ---> https://www.facebook.com/WantedKidneyDonor
Please watch her video: http://youtu.be/D9ZuVJ_s80Y
Living Donors Rock! http://www.livingdonorsonline.org -
News video: http://www.youtube.com/watch?v=J-7KvgQDWpU
okarol
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« Reply #7 on: December 07, 2007, 11:39:54 AM »

Contact info for newspaper:

We Look Forward To Hearing From You

Our Mailing Address Is:
23 Exchange St.
Pawtucket, RI 02860
Phone: (401) 722-4000

E-mail our newsroom at editor@pawtuckettimes.com
Phone: (401) 727-9292
Newsroom fax: (401) 727-9280
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Admin for IHateDialysis 2008 - 2014, retired.
Jenna is our daughter, bad bladder damaged her kidneys.
Was on in-center hemodialysis 2003-2007.
7 yr transplant lost due to rejection.
She did PD Sept. 2013 - July 2017
Found a swap living donor using social media, friends, family.
New kidney in a paired donation swap July 26, 2017.
Her story ---> https://www.facebook.com/WantedKidneyDonor
Please watch her video: http://youtu.be/D9ZuVJ_s80Y
Living Donors Rock! http://www.livingdonorsonline.org -
News video: http://www.youtube.com/watch?v=J-7KvgQDWpU
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« Reply #8 on: December 07, 2007, 12:50:08 PM »

I have the name of the union president and a contact number for him.  His name is Lt Robert Neill, he is a firefighter.  The contact number is 401-725-1422.

I will be contacting him with a verbal message that, in my opinion, based on the news report, the dispatcher should NOT be reinstated.  A 911 call came in, help was not dispatched in a timely manner, and a woman died, and to me that's enough to warrant permanent dismissal.  The claim from the fire department that the language barrier is mostly to blame for this is, to me, an unacceptable excuse.

I also intend to email the paper and ask for a follow up on this situation.

I also contacted the paper by phone and suggested that it might be a good idea to write a story about how important a rapid response is when a dialysis patient calls 911 and says they are bleeding, and especially focus on how many thousands of patients live with the knowledge that bleeding from a dialysis access is a life-threatening emergency.

BTW, the young woman at the paper emphasized that she had to remain neutral and objective but said that she too was surprised that this horrible event took place.
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Lorelle

Husband Mike Diagnosed with PKD Fall of 2004
Fistula Surgery  1/06
Fistula Revision  11/06
Creatinine 6.9  1/07
Started diaysis 2/5/07 on NxStage
Black
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« Reply #9 on: December 07, 2007, 06:58:49 PM »

I sent the following email to the paper.

The Death of Maria G. Carvalho

Thank you so much for the follow up on this horrible event.  This should never have happened, and I hope will never happen again.  Fifty three is far too young to die, but it is especially despicable that death came because someone decided that a 911 call for help should be disregarded.

Every dialysis patient, and everyone in their family, lives every hour of every day with the knowledge that bleeding from their access site is a life-threatening event.  As the wife of a dialysis patient, I cannot imagine having him bleeding from his access site, calling 911 as his medical team has instructed, and not having anyone sent to answer the call until after he has bled to death! 

Your paper is in a position to continue to call attention to this serious lack of judgement and prevent the two people who disregarded that call ever being in the position to do so again.  I hope you do so.
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Lorelle

Husband Mike Diagnosed with PKD Fall of 2004
Fistula Surgery  1/06
Fistula Revision  11/06
Creatinine 6.9  1/07
Started diaysis 2/5/07 on NxStage
okarol
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« Reply #10 on: December 07, 2007, 10:19:00 PM »

 :thumbup; Well done.
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Admin for IHateDialysis 2008 - 2014, retired.
Jenna is our daughter, bad bladder damaged her kidneys.
Was on in-center hemodialysis 2003-2007.
7 yr transplant lost due to rejection.
She did PD Sept. 2013 - July 2017
Found a swap living donor using social media, friends, family.
New kidney in a paired donation swap July 26, 2017.
Her story ---> https://www.facebook.com/WantedKidneyDonor
Please watch her video: http://youtu.be/D9ZuVJ_s80Y
Living Donors Rock! http://www.livingdonorsonline.org -
News video: http://www.youtube.com/watch?v=J-7KvgQDWpU
KT0930
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« Reply #11 on: December 09, 2007, 01:19:09 PM »

Excellent, Black!

Her husband spoke limited English and ran to a neighbor's house to call 911. But emergency recordings show they refused to send help, saying the call had to come from Carvalho's own house.

I don't understand this line at all. What about when a neighbor calls and complains about a couple arguing? The police come then. Why can a neighbor not be a "good" neighbor and call when someone is in a medically life-threatening situation? I can't imagine this argument would stand up in court. This whole situation is disgusting.  >:(
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"Dialysis ain't for sissies" ~My wonderful husband
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« Reply #12 on: December 09, 2007, 04:57:00 PM »

I think I will copy and paste Blacks letter and add a few things, then send that to them as well. As long as you don't mind Black.
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Black
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« Reply #13 on: December 10, 2007, 05:45:14 PM »

Don't mind at all.  I'd love to see mail bouncing because the in box is full.
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Lorelle

Husband Mike Diagnosed with PKD Fall of 2004
Fistula Surgery  1/06
Fistula Revision  11/06
Creatinine 6.9  1/07
Started diaysis 2/5/07 on NxStage
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