On the morning of October 1, 1992, Tina Knox, a 29-year-old aerobics instructor, gave birth to a healthy baby boy at Littleton Hospital. Twenty-four hours later Tina was dead, killed by a rare but treatable condition related to her pregnancy.

Three years later, Tina's son, Preston, is a toddler; her husband, Brett, has remarried and, his attorney says, "gone on with his life."

But the finger-pointing is not over. "What really pisses me off," says Leonard Goldstein, Knox's lawyer, "is that nothing ever happened to Littleton Hospital."

On that, and perhaps only on that, he and Tina Knox's doctor are in complete accord.

Hours after she delivered her baby, Tina began complaining of severe pain. According to court documents, she repeatedly asked for her obstetrician, Dr. Terry A. Downing, but her complaints were generally dismissed as normal postpartum aches and pains.

As it turned out, however, Knox was suffering from HELPP syndrome, a rare hypertension condition associated with pregnancy. HELPP syndrome rarely comes on quickly, and it's usually diagnosed during monthly prenatal visits through such procedures as monitoring blood pressure, checking urine samples and questioning the patient about headaches, weight gains and swelling, according to a nurse who specializes in high-risk maternity cases.

If diagnosed properly, HELPP is treatable. Left to run its course, it can be fatal.

Tina's condition was not diagnosed prior to the birth of her child. Her blood pressure was elevated when she was admitted, but it apparently caused no alarm.

And after delivery, according to court documents, a nurse twice failed to check Tina's blood pressure--which would have indicated the hypertension--because she had misplaced her stethoscope. Then, when called by the nurses, Downing prescribed drugs for his patient by phone and didn't return to the hospital until after Tina had slipped into a coma at 2 a.m., October 2. By then her liver had ruptured and she suffered intercranial bleeding. Tina Knox died at 7:25 a.m.

The blame game started almost immediately. In February 1993 Brett Knox sued Downing and the hospital for negligence leading to the wrongful death of his wife. His suit charged that the doctor had failed to provide "proper medical care and supervision" between leaving the hospital after delivering Preston and returning eighteen hours later when Tina was already comatose. The lawsuit also claimed that Downing had failed to diagnose and properly treat Tina for HELPP syndrome "and prescribed narcotics which masked the true nature of her condition, thereby breaching the standard of care exercised by other physicians specializing in obstetrics and gynecology."

Knox's charges against the hospital included the revelation that a nurse, Sarah Strong, had replaced the original charts on his wife with altered versions in the hours following Tina's death. When hospital officials learned of the substitution, "a decision was reached not to reveal the alteration," the lawsuit claimed, and the switch was admitted to Knox "only at a time when it became apparent to the Defendant Littleton Hospital that the information of the altered records was to be revealed by an independent source."

The hospital, whose lawyer also represented the nurses, denied any wrongdoing. So did Downing. And after Knox filed his suit, Downing lodged cross-claims against the hospital and its staff for negligence--accusing the nurses of incompetence and failing to communicate the level of Knox's distress and arguing that the hospital knew or should have known that its nurses were improperly trained to deal with such situations.

Soon thereafter, Littleton Hospital's medical board revoked Downing's privileges, citing his treatment of ten patients between October 1992 and February 1993.

In February 1994 the state Board of Medical Examiners, which is charged with licensing and monitoring physicians practicing in Colorado, asked the Attorney General's office to investigate Downing's handling of those ten cases as well as three others, including the death of Tina Knox.

Brett Knox's suit against the doctor and the hospital was settled in March 1994. Terms of the settlement were not disclosed.

But the legal entanglements did not end there. The hospital sued Downing for his share of the settlement costs. And Downing filed another lawsuit--against Littleton Hospital in Arapahoe County District Court. The lawsuit charged violations of the Colorado Consumer Protection Act because the hospital promoted itself as a "place that provided quality patient care to try and attract physicians," says Deanna Dagner, Downing's attorney. "And this hospital failed abysmally."

In this suit, Downing claims that he became a scapegoat in Tina Knox's death and that members of Littleton Hospital's medical board "are all direct competitors of his and therefore stood to gain financially by the actions of the hospital." According to the suit, "Dr. Downing will further testify to the fact that the poor nursing care related to Tina Knox was actively concealed from both him and the public in general."  

Downing also filed a complaint with the Board of Medical Examiners' committee on anti-competitive conduct, claiming that by revoking his privileges, the Littleton Hospital staff was placing an unfair burden on his ability to compete with it for patients.

The committee was established by the legislature in 1989 so that physicians who believe the peer-review systems of a hospital or health-maintenance organization unfairly limit their ability to do business have recourse outside of court, according to Susan Miller, spokeswoman for the medical board. Explains Miller, "Say some physician has lost his privileges at a hospital but feels it wasn't for his medical care but because the doctors at the hospital thought they had too many people in a specialty and wanted to eliminate the competition."

The committee, which was formed to protect individual doctors on peer-review committees from lawsuits, generally receives one or two complaints a year and acts as a judge, ruling on complaints and making final determinations. If losers want to appeal, they must do so in court. "They also have to pay all the costs of the litigation, which can be expensive," Miller says.

In February Downing reached an agreement with the Board of Medical Examiners and the AG's office, admitting that his care in two of the ten cases cited by Littleton Hospital failed to meet "generally accepted standards of medical practice." But he denied that his conduct in any of the other cases was improper, and the medical board determined that "no finding is made as to the remaining cases." The board placed Downing's license to practice medicine in Colorado on probationary status for five years. During that time, he must accept a "practice monitor"--a physician who reviews patient charts from Downing's office and the hospitals he uses every month. He also had to agree to a recertification examination by the American College of Obstetrics and Gynecology; to take other classes, including a high-risk-obstetrics course; and to meet with two mentors once a month for a year.

According to Dagner, Downing is following all the terms of his probation. "It was a settlement he agreed to so that he wouldn't have to spend a bazillion bucks defending himself," she adds. Downing did not return calls from Westword.

The medical examiners' board also dismissed Downing's complaint against Littleton Hospital. His lawsuit against the hospital, however, is still pending--and was kicked into gear earlier this month because of the dismissal of the complaint.

Dagner says she and her client waited a year for the judge to rule on the hospital's motion to dismiss Downing's suit. "Arapahoe County is kind of famous for this," she says. "It's the longest case I have going now."

But according to Deborah Smith, an attorney for the hospital, the judge had been waiting for Downing to conclude his administrative appeals at the hospital. And in a decision dated November 6, Judge Joyce Steinhart determined that Downing has indeed exhausted those appeals and must now move for a trial date if the lawsuit is to go forward.

Dagner filed such a motion on Downing's behalf two weeks ago.
Included in the evidence she plans to introduce at trial against Littleton Hospital, Dagner says, is a 65-page report prepared by a nursing consultant that cites violations of state and federal nursing regulations at the hospital. "The Board of Nursing is using it now for its own investigation," she adds.

That board "received copies of all kinds of reports from the family, the doctor's lawyer, the nurses' lawyer...everyone involved," says Linda Siderius, a lawyer with the Attorney General's office who is assigned to the nursing board. "But my client agency did its own investigation irregardless of any information and reached its own conclusions."

After the board's investigation, Sarah Strong, who'd been accused of altering the charts, was suspended from working as a nurse in Colorado. She has since moved out of state. Three nurses involved in the Tina Knox case were put on probation; two more received letters of admonition from the board. And action is still pending against a seventh nurse, after "an associated investigation arose as a result of the Knox investigation," according to board spokeswoman Karen Brumley.

The Colorado Department of Public Health and Environment, which is charged with investigating hospitals following any questionable death of a patient, took no action against Littleton Hospital after Tina Knox's death. That irks Brett Knox's attorney.

"Nothing can relieve Terry Downing of his responsibility for what happened," Goldstein says, "but I think there's some truth to what he is saying.

"Littleton Hospital skated. They gave up their nurses--as they should have--but nothing was ever done to the hospital."  

"I don't know what he wants," says Deborah Smith, the hospital's lawyer. "State and federal agencies found the hospital to be in compliance. The state conducted its own investigation and decided not to take any licensing action. I'm sure if there was a problem, they would have.

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