This story has been told for years, and it deserves to be told again. It’s the tale of 49-year old Beatrice Vance, who in July of 2006, arrived in the Vista Medical Center Emergency Room in Lake County, Illinois complaining of chest pain, nausea and shortness of breath.
Despite these textbook heart attack symptoms, Beatrice was not seen immediately by E.R. physicians, but was instead told to sit down in the waiting room. So she waited. And she waited. And by the time the E.R. nurse finally called her name two hours later, Beatrice Vance was slumped in her chair, already dead.
The coroner’s report determined that this heart attack was caused by a blocked coronary artery, and contributing factors were delayed and inadequate treatment.
Much later, in a truly startling decision, a coroner’s jury investigating the Beatrice Vance case didn’t just cite the hospital, but it declared this death a homicide in its ruling against the E.R. physicians and nurses working that night. The jury found that the death was “a result of a gross deviation from the standard of care which a reasonable person would exercise in the situation.” Illinois State’s Attorney Michael Waller said at the time that this was the first time in his 30-year career that an emergency room heart attack death was ruled a homicide.
On that terrible summer night in 2006, Beatrice was accompanied to the E.R. by her 28-year-old daughter Monique, who is a nurse herself. Monique reported that her mother was left to die in the waiting room, after moaning in pain for two straight hours. Dr. Richard Keller, the coroner of Lake County, described the scenario to NPR interviewers:
“Ms. Vance and her daughter Monique arrived in the Emergency Department at about 10:15 p.m. She was not called back until about 12:25, two hours later. Meanwhile, her daughter was becoming increasingly frustrated as they sat there and waited, as she saw her mother appearing to get more and more ill.
“Monique went to the staff at least five times and asked them to pay attention to her mother. In fact, she was so frustrated that she even considered calling 911 to see if that would make an impact.
“Beatrice Vance certainly needed immediate care. She presented with classic heart attack symptoms, and certainly somebody presenting with those symptoms should have been seen emergently, which is within 10 minutes. She should have had at least an electrocardiogram (EKG) done within 10 minutes of her arrival.
“Ms. Vance also died of a heart attack that our clot-dissolving drugs were made for. She had a blood clot in the middle of her coronary artery, and had she been given those life-saving drugs, they would have saved her life. There’s no doubt about it.”
NPR asked Dr. Keller if he had expected the homicide ruling when his coroner’s jury report was first presented. He explained that a finding of homicide had certainly been an option they had considered. But it would have been just as easy, he said, for the jury to come up with an undetermined determination, another of their available options. This finding would essentially say that jurors could not be sure if the hospital should be taken to task for clinical outcomes.
In the case of Beatrice Vance, however, the coroner’s jury was quite sure. In a move that patients cheered (but hospitals cringed at), the coroner ruled her death as a homicide.
Dr. Keller added that he was not surprised by the jury’s findings:
“The definition of homicide that I give to the jury is either a willful and wanton act or recklessness on the part of someone, whether that’s by their actions or by their inactions. Certainly, by that definition, this death is a homicide.”
One of my sister heart attack survivors later wrote about this case and its implications for how women are treated during their cardiac events:
“I remember that I was driving in the car when I first heard on the radio about this coroner’s inquest verdict in 2006. I was riveted that a doctor had finally, unequivocally, challenged the medical dismissiveness directed at women in cardiac distress. Homicide!
“I waited for the fallout, because this was public and couldn’t be bought off (settlements with non-disclosure agreements). Sure enough, suddenly several prominent teaching hospitals put the door to balloon protocol* into ‘testing mode’, although it had been first created in 1999 but ignored.
“Even if women overcome our upbringing to always be “nice” and “don’t make waves” and all that – and as a Southern female, I tended to get a double-dose of it when I was growing up – it’s incredibly difficult to be assertive when you’re in a flimsy, backless hospital gown and the person across from you is fully dressed, wearing a white coat and has the initials M.D. after his or her name.
“The Beatrice Vance story is as pivotal as the Anita Hill story.”
And meanwhile, on April 30, 2007, in Washington, DC, WomenHeart: The National Coalition for Women with Heart Disease presented Dr. Richard Keller, the coroner of Lake County, with their 2007 Wenger Award for Excellence in Public Policy. The WomenHeart news release at the time read:
“The award was granted based on the events surrounding the death of Beatrice Vance on July 29, 2006. Her death investigation results were taken to inquest and the jury, based on the facts of the case, found homicide to be the manner of her death from an acute myocardial infarction. Their verdict was based on their opinion that the death resulted from “a gross deviation from (the) standard of care which a reasonable person would exercise in the situation”.
“The case at the time of verdict engendered considerable national media attention, including medical media outlets for the American Medical Association and American College of Emergency Physicians.
“Since that time, the Beatrice Vance case has been used in teaching women to advocate for themselves, in teaching at medical schools and to hospital medical staff around the country. It continues to bring about personal change and is serving as a catalyst for system change, so that her death is not repeated elsewhere.
“During his acceptance speech, Dr. Keller admonished those present:
“Push for changes in emergency care, nationwide, so that it becomes impossible for a 49-year old woman to die of a treatable disease process 20 feet from diagnosis and treatment.
“The problem here is bigger than a problem at a single hospital – it is a system problem. No one should be prosecuted for her death, but it should not be disregarded, either. We must do everything we can to forestall death, to keep folks out of the coroner’s office for as long as possible.”
Sadly, seven months after Beatrice Vance died in that E.R. while waiting for life-saving cardiac care that never came, the Lake County State’s Attorney’s Office decided not to pursue criminal charges against Vista East Medical Center or any staff member. Matthew Chancey, chief of the criminal division, announced at the time:
“After a careful review, it is the determination of this office that there is insufficient evidence to support the filing of criminal charges against any person or institution.”
After the coroner’s inquest, Chancey headed an investigation to determine whether criminal charges were supported by the evidence. Major hurdles for criminal charges, he said, were “being able to show recklessness is a problem.”
* door-to-balloon time = the time between the moment a patient with a possible acute myocardial infarction (heart attack) enters a hospital’s Emergency Department and the moment when that patient undergoes balloon angioplasty to help re-open a blocked coronary artery. Current protocols recommend a door-to-balloon goal of ≤ 90 minutes for optimal outcomes.