How did we get here? Robin Valdez asked himself that question as he sat with his mother on her hospital bed, rubbing her back and trying to soothe her agitation and pain. It had been a week since Ruth Farfan had come to St. Anthony Central for surgery, and her condition had been getting worse every day. Now she wanted to stand up, but Valdez could tell that she didn’t have the strength to do it.
In the corridor, hospital staffers conferred about the patient’s dangerously high potassium level — a sign of possible kidney failure — and about moving her to the intensive-care unit. A nurse came in and told Valdez that they were discussing whether to call the emergency team.
“Call it,” Valdez said. “Call it now.”
Soon the room was full of doctors and nurses and aides. They asked Valdez to step outside. He glanced back at his mother. “That was the last time I saw her with some sort of awareness of what was going on,” he says.
The patient was moved to the ICU. Less than two hours later, someone came out and told Valdez that his mother had gone into respiratory failure and had been placed on a ventilator.
How did this happen? How did something so routine turn into such a nightmare?
Ruth Farfan was 68 years old. She’d been in relatively good health when she’d checked into the hospital on July 5, 2012, for repair of a hiatal hernia. It’s a fairly common operation, often done laproscopically, with only small incisions. Farfan wasn’t terribly worried about it, or about going into a hospital. A Denver native who’d moved to Ecuador with her husband when she was young, then returned to Colorado to raise five children on her own, Farfan had worked at St. Anthony as an administrative assistant for almost thirty years before being let go during a recent “restructuring” of the staff.
Farfan’s adult children were also perhaps more savvy about the health-care business than the average consumer. One daughter worked at University of Colorado Hospital. Valdez was the director of the community-health division of the Denver Department of Environmental Health. Before that, he’d worked as an operating-room tech for ten years for Centura Health, the company that runs St. Anthony in conjunction with Catholic Health Initiatives. Valdez knew many people in the Centura hospital system, and he knew that his mother’s surgeon, Dr. Nelson Mozia, had performed operations at St. Anthony and Lutheran hospitals for years.
Yet over the critical week following her surgery, Farfan and her family found themselves increasingly bewildered and in the dark about what was going on.
Initially, it seemed as if the operation had gone well. Farfan was heavily medicated when Valdez first got in to see her, but there was nothing unusual about that. Family members had little interaction with Dr. Mozia; three days after the surgery, another physician came to examine Farfan and discharge her, even though she was complaining of pain in her lower abdomen and of not being able to urinate.
At home, Farfan spent much of her time sitting on the couch, taking her prescribed pain medication and “not doing well,” Valdez says. When her pain and nausea became more severe the next day, another son called for an ambulance to take her to the emergency room at St. Anthony. After CT scans were taken, she was soon back in surgery.
“Dr. Mozia came out and said he repaired the hernia and she should be able to get back home in a couple of days,” Valdez recalls. “We stayed with her. There was always one of us at the hospital with her. I didn’t know what to think at this point, but there was something wrong.”
According to Valdez, it was difficult to get any information about exactly what was wrong, or even what lab tests had been done. Meanwhile, his mother continued to decline. She seemed weak and lethargic, in a mental fog as well as in pain. Then came the rising potassium, the emergency team and the move to the ICU.
Shortly after Farfan was sedated and put on a ventilator to help her breathe, one of her daughters met with a patient advocate employed by St. Anthony and expressed her concerns about Farfan’s care. The advocate took notes and promised to get back to her. Valdez says the family never heard from the advocate again, despite repeated phone messages asking her to call them.
The next morning, family members met with Mozia and the hospital’s chief of staff, Joseph Heit. The doctors explained that Farfan was suffering from septic shock. They mentioned the possibility of a third surgery, which they described as “exploratory” — implying that they did not yet know the causes of her condition. In a subsequent conversation, Heit suggested that the family might want to consider another St. Anthony doctor to provide a second opinion and possibly to perform the surgery.
“He stated that regardless of what we chose, the administration is following this closely, and the hospital surgical team would be following Dr. Mozia’s surgical care,” Valdez says. “To me, that raised a lot of red flags and huge concerns.”
Valdez wasn’t sure how to respond to Heit’s suggestion. The chief of staff hadn’t actually said anything negative about Mozia — who had represented each of his prior operations as a success. Why wouldn’t the family want to use the surgeon who was already familiar with the case, especially when he had such a long and illustrious track record at the hospital?
In the end, Farfan’s family elected to go with Mozia. On July 18, he performed the third surgery, then reported to the family that he’d irrigated the patient’s abdominal cavity and that she “should be on the mend,” Valdez recalls. That was the last any of the family heard from the surgeon.
Over the next two days, Valdez and three of his siblings took turns holding vigil in the ICU as Farfan’s condition spiraled downward. There was talk of organ failure and dialysis and end-of-life wishes. On July 21, shortly after nine in the morning, Farfan died.
Hospital staffers offered their sympathies but had little else to say. It wasn’t until Valdez obtained copies of his mother’s medical records, read the autopsy report and started digging around on his own that he began to realize just how much the providers at St. Anthony hadn’t told him. About Dr. Mozia and prior issues with his performance. About a serious medical mistake committed in the operating room, one that the two subsequent surgeries failed to correct. About all of the meetings held by staffers, surgeons and administrators regarding Farfan’s condition and what to do about it, meetings that hadn’t involved any consultation with the family at all.
“They withheld critical information that would have made a difference in my mother’s life, in terms of what treatment would have been available to her,” Valdez says. “I never thought this would happen to me. It shook my foundation, the trust I’ve had in the system I’ve worked in for thirty years.”
Farfan’s children are now suing St. Anthony and Centura Health over the death of their mother. The Jefferson County case isn’t a simple malpractice suit — the family has already reached a confidential settlement with Dr. Mozia — but involves a claim of “negligent credentialing.” The lawsuit contends that hospital officials were aware of numerous red flags concerning Mozia’s competence, including previous malpractice cases, yet continued to grant him privileges at St. Anthony — and then failed to take appropriate action when it became apparent that Farfan’s surgery had been botched.
In Colorado, cases involving what hospitals know about their doctors but don’t disclose to their patients tend to generate a legal brawl over access to internal hospital records. Health-care providers insist that their internal investigations and evaluations of doctors’ mistakes are strictly confidential, protected by state laws dealing with health-care quality management and peer-review processes. Staffers wouldn’t volunteer their honest opinions about a colleague’s work, they say — and the care therefore wouldn’t improve — if the whole process wasn’t confidential. But plaintiffs’ attorneys maintain that hospitals and nursing homes often invoke the quality-management and peer-review laws in an effort to deflect legal liability and cover up bad care.
“It’s a common move, using QM to prevent access to critical evidence,” says attorney John Holland, who frequently takes on cases involving substandard care at nursing homes. “It’s bad enough that you get smashed or broken or killed, but then they say, ‘We need to study this for the future, so we can’t tell you what we actually did.’”
The battle over records in the Farfan case has been particularly heated. Attorneys for St. Anthony have resisted turning over various documents, including nearly a thousand pages of documents dealing with the credentialing of Mozia, insisting that such material is privileged. They have taken the position that even the names of the staffers who serve on their peer-review and credentials committees must not be disclosed, for fear of piercing the veil of confidentiality. But Valdez’s attorney, Hollynd Hoskins, says that a system that was supposed to improve patient safety is being used to bury information that patients — or their survivors — have a right to know.
“A hospital has a duty to make sure the physicians they have operating there are competent,” Hoskins notes. “It’s outrageous that you have somebody in the hospital over fifteen days, and numerous hospital administrators are involved, and they did nothing to take Mozia off the case. But they’re saying all the facts are confidential. These are facts that should be documented in a patient’s record and disclosed to the family, but they’re being hidden away under the guise of peer review.”
Hospitals tend to market their physicians as not merely competent but irreproachable, a crack team possessed of superhuman skills, boundless compassion and impeccable bedside manners. The reality is, of course, all too human. Hospital mistakes — operating-room goofs, surgical-site infections, overmedications and more — account for an estimated 200,000 to 440,000 deaths a year, making medical errors the third leading cause of death in the United States.
In an effort to drive the error rate down, the industry has put increasing emphasis on patient safety, including beefed-up peer-review and quality-management practices. At least one study of North Carolina hospitals suggests that such measures have failed to make much of a dent in the rate of “preventable harms.” But advocates of the current internal, top-secret review system say that patients would be a lot worse off without it.
“In medicine, there are going to be errors,” says state senator Irene Aguilar, a physician who has served on the Colorado Board of Medical Examiners. “Some of them are expected — which patients don’t like to hear. Others are possible but not frequent, and others occur because someone didn’t know what they were doing. How do you tell the difference? In some areas that are so specialized, only someone working in the field can tell you that.”
Aguilar led the charge to renew the state’s professional-review statute in 2012, the last time it was up for sunset consideration. She regards peer review as an added consumer protection to what state regulators can do, a way for hospitals to police the quality of their own providers.
Keeping the process confidential, she says, creates a “safe zone” for professionals, making it easier to air their concerns about bad doctors without fear of being sued or accused of acting out of spite.
The 2012 changes to the law allow patients to sue hospitals for negligent credentialing, taking away their immunity to such claims. At the same time, the changes strengthened the confidentiality of records dealing with the credentialing process, making it more difficult for such claims to succeed. The paradoxical language has been a point of contention among attorneys defending hospitals and those representing patients ever since.
Consumers do have other sources of information about doctors, without trying to probe internal hospital records — the Internet, for example. Doctors are now reviewed online, their services scrutinized like those of plumbers and mechanics. But there’s no quality assurance in anonymous reviews, which can be wildly contradictory and misleading.
“It’s really hard for laypersons to know whether a doctor is good or not,” Aguilar notes. “You can be a jerk and be a really good doctor. On the other hand, you could be a horrible doctor but be so personable that nobody ever complained about you.”
With only a couple of exceptions, the online reviews of Nelson Mozia describe him as an outstanding surgeon. “Dr. Mozia saved my life,” says one commenter.
“Out of three specialists seen, he was the only one to accurately diagnose me,” says another.
“I probably wouldn’t be alive today if it weren’t for him,” says a third.
According to an online biography, Mozia was born in Nigeria. He decided to become a colorectal surgeon after his mother, a midwife, died of colon cancer on his eighteenth birthday. He did his resident training in Ohio and received his Colorado medical license in 1981. He’s since been named one of “Denver’s Top Doctors” by 5280 magazine sixteen times — right up until his privileges at St. Anthony were suspended, then revoked, following Ruth Farfan’s death in 2012.
Mozia voluntarily surrendered his medical license in 2013. Now retired, he declined an interview request from Westword. His attorney, Robert Ruddy, says that the confidential settlement with the family, as well as patient-confidentiality concerns, prevent his client from commenting on the Farfan case. Ruddy provided a statement noting that Mozia “had a busy surgical career since the early 1980s and was board-certified in both general and colorectal surgery. His care was sought by thousands of patients, and he was recognized as a top-notch surgeon a number of times.”
But not every patient was happy with Mozia’s work. Court records indicate that he was sued for malpractice or negligence eleven times over a twenty-year period. In some of the cases, Mozia prevailed. But at least five of the claims, including the Farfan case, resulted in a confidential settlement.
Given his “busy surgical career,” it’s not all that surprising that a top-rated doc was also frequently embroiled in litigation. In addition to his own practice, Mozia had on-call-specialist contracts with St. Anthony and Exempla Lutheran Medical Center. For many years he was an on-call vascular surgeon for St. Anthony; several of the complaints against him point out that he isn’t board-certified as a vascular surgeon.
Mozia reported malpractice settlements to the Colorado Medical Board in 1998 and 2008. In 2010 he reported that his privileges at Lutheran had been restricted. They were reinstated in 2011, but with limits on the number of surgeries he could perform and requirements that he be closely monitored and consult with other specialists on the patients he admitted to Lutheran — indicating, perhaps, that he was taking on more work than hospital officials believed was advisable.
According to state records, in 2011 Mozia attempted a skin graft on the foot of a fifty-year-old diabetic but didn’t take all the follow-up actions the medical board deemed necessary. The graft failed, and eleven days later the patient’s leg was amputated above the knee. Mozia also repaired a bowel obstruction in an 85-year-old patient but failed to document any follow-up care for five days. In a disciplinary procedure before the board, Mozia admitted that his actions in those two cases amounted to “unprofessional conduct,” and his license was put on probation for five years. But that order didn’t become final — and thus available to the public — until 2013, by which time Mozia’s care of three other surgery patients had come under attack.
One of the patients was a woman who’d fallen and dislocated her knee while hiking on Mount Evans. As the vascular surgeon on call, Mozia examined her at St. Anthony. According to the complaint in a lawsuit filed by the woman’s attorney, Mozia failed to perform surgery to repair a damaged artery detected by a CT scan. He discharged her several days later, despite a radiologist’s concern about swelling in the leg and the potential for compartment syndrome — a condition that can lead to serious problems with blood flow. Less than two months later, the patient was back in another emergency room, where it was determined that her gangrenous left leg would have to be amputated above the knee. The woman eventually reached a confidential settlement with Mozia. (A claim of negligent credentialing against St. Anthony went to trial, and the jury decided in the hospital’s favor.)
The second patient suffered damage to an artery while undergoing knee-replacement surgery at Ortho Colorado Hospital, an orthopedic clinic jointly operated by physician investors and Centura Health. Mozia was summoned as the vascular specialist to repair the artery. He made “multiple, unsuccessful attempts to repair the damage,” according to the patient’s lawsuit. Two weeks after the knee surgery, the increasing complications in the case had resulted in an above-the-knee amputation. That case, too, resulted in a confidential settlement.
The third patient was Ruth Farfan.
Farfan and her family didn’t know about the recent amputations. The lawsuits hadn’t yet been filed at the time Farfan was admitted to St. Anthony for hernia surgery. Doubtless Mozia’s insurance carrier and his supervisors already knew something about those cases, but it wasn’t the kind of information the surgeon was inclined to volunteer to another patient. Valdez says that Farfan had wanted to have her surgery at Lutheran, but Mozia had insisted on doing it at St. Anthony — without mentioning the restrictions that had been imposed on him at Lutheran.
As Valdez discovered in the grim aftermath of his mother’s death, there was a great deal about what happened during her surgeries that Mozia had failed to disclose, too. The autopsy report states that Farfan’s death was caused by complications of sepsis and peritonitis from perforation of a gastric ulcer. According to the lawsuit filed by the family, Mozia perforated the patient’s bowel in two places during his initial surgery. Those injuries were visible in CT scans taken when Farfan returned to the hospital four days after surgery, complaining of pain and nausea. Mozia reviewed those images, yet only repaired one of the areas in the second surgery.
Valdez says that none of the family members were told anything about the perforations suffered in the first operation, or the fact that only one of them was addressed in the second. They were not informed of the error even after Farfan was rushed into the ICU, suffering from septic shock. The same day that Mozia and Heit, the chief of staff, met with family members to discuss an “exploratory” third surgery, additional CT scans confirmed the presence of an unrepaired injury to the bowel. Over the next several days, as more staff and administrators got involved in reviewing the scans and Heit gently suggested that bringing in another surgeon might be a good idea, the family remained uninformed about the true causes of their mother’s condition. The situation continued right through Mozia’s third operation — which, the lawsuit claims, also failed to repair the bowel injury.
Records indicate that Mozia didn’t get around to dictating his operative reports for all three surgeries, which represent critical data for anyone trying to review what went on in the operating room, until two in the morning on July 20, 2012. That was more than two weeks after the first operation and less than 36 hours before Farfan died.
St. Anthony officials declined a request for comment on the Farfan case because of ongoing litigation. In a court filing, the hospital’s attorneys have designated Mozia as a “nonparty at fault,” claiming that he breached his duties as a physician by, among other things, “failing to appropriately and timely document findings, treatments and plans for the care of Ruth Farfan,” as well as “failing to advise other medical professionals at St. Anthony Hospital if he felt incapable of appropriately caring for Ruth Farfan.” In other words, the hospital is claiming that Mozia didn’t share vital information about the case with his colleagues, either.
Valdez says he’s disappointed that hospital officials didn’t tell him what they knew about Mozia’s prior problem cases; if the family had known about those earlier, it’s unlikely the first surgery ever would have happened, let alone the third. He also wonders what went on in the huddle-ups among doctors and administrators who reviewed Mozia’s care of his mother over the last two weeks of her life — discussions that the hospital’s attorneys say are strictly confidential, shielded by the peer-review and quality-management laws.
“This is institutional behavior,” Valdez says. “Typically, one physician is not going to say anything against another. Being an active consumer is important. People need to research who they’re going to use for medical care, and you really have to dig deep. But when you get to the heart of it, hospitals rely on the peer-review and quality-management privilege to not be transparent, to not be as truthful as they should be.”
There was not a lot of time to make the decision. David and Patricia Skolnik were told that their son Michael needed surgery right away.
The 22-year-old nursing student had mysteriously passed out on his couch at home. A doctor suggested that he’d had a seizure, a possible side effect of medication he was taking to help quit smoking. But a young neurosurgeon told the Skolniks that CT scans had detected a small cyst in his brain, and it had to be removed immediately. The neurosurgeon described the procedure as a simple operation.
Michael Skolnik and his parents didn’t know that this was only the second time that the neurosurgeon had attempted such an operation. They didn’t know about prior malpractice claims against him, or that he’d practiced in two other states before coming to Colorado.
The operation failed to locate any cyst. Complications from the surgery led to additional surgeries, infections, paralysis, system failures, partial blindness. In 2004, after nearly three years of painful struggle, Michael died.
Determined to make changes in honor of her son’s memory, Patty Skolnik became a nationally recognized advocate for reform. The nonprofit that she founded, Citizens for Patient Safety, served as the driving force behind state legislation requiring more public disclosure from medical professionals about their qualifications, affiliations and mistakes. Under the 2007 Michael Skolnik Medical Transparency Act, physicians must report their certifications and specialties, any businesses they own that provide health-care services, disciplinary actions and restrictions of privileges, malpractice settlements, criminal convictions, and more — all of which is noted in a physician’s profile that’s publicly accessible on the Colorado Department of Regulatory Agencies website. The law was expanded in 2010 to cover nurses as well, and in 2013 to apply to a wider range of licensed health-care providers.
The DORA profiles don’t list malpractice lawsuits that are still ongoing, or ones that were resolved with no money changing hands. They also don’t include disciplinary actions that have not yet been finalized — which, as in Mozia’s case, can take years. But Colorado’s disclosure requirements are now among the toughest in the nation. After initial resistance to the changes, Skolnik says, many Colorado health-care professionals have discovered that the information on the website is useful to them as well as consumers.
“They’ve told me they’re actually using it to look up doctors before they refer,” she says.
Transparency laws are part of a growing movement in health care to handle medical errors differently than in the past — a shift away from lawyering up and toward candor. Some hospitals now emphasize a speedy response when doctors do something wrong: a thorough yet prompt investigation, followed by explanations to the patient and family members — and, if warranted, timely apologies and compensation.
Skolnik says the process of keeping families informed about errors can actually result in a drop in malpractice claims. “People are angry, but they also want to know what happened,” she says. “This approach is much more humane. The family is taken care of, and the medical staff is taken care of. A lot of the doctors want to talk about it. They want to apologize. The whole thing of hiding this is going away — but very slowly.”
In many instances, however, the old adversarial system for thrashing out legal accountability for medical errors remains in effect. Plaintiffs’ attorney Holland says that he usually begins his investigations of allegedly poor care at nursing homes by seeking out the reports made by staffers who witnessed the incident. But defense attorneys often insist that such records are part of the internal review of what went wrong.
“Fifty percent of the time, there’s no account, or it’s very minimal,” Holland says. “They’re collecting incident reports and calling them confidential. Quality management and peer review are part of the system, but so is medical record-keeping. They’re violating their function and diverting the evidence to try to shield it from discovery.”
Colorado’s law states that the records of a professional-review committee, such as a hospital committee that issues privileges to physicians and investigates their conduct, can’t be subpoenaed and aren’t admissible in a civil suit. But a 2014 Colorado Supreme Court decision held that the facts underlying internal investigations aren’t privileged. “The tide is swinging back to the recognition that we’re not actually investigating Guantánamo Bay in these cases,” Holland notes.
Disputes over what constitutes patient records and discoverable facts, as opposed to “professional-review activities” that are immune to outside scrutiny, have played a large part in the Farfan lawsuit. St. Anthony’s attorneys have argued that the hospital’s thick file on Dr. Mozia — which spans decades of credentialing actions and evaluations, as well as materials related to the internal review of his care of Farfan — is completely confidential. St. Anthony has been reluctant to release the notes taken by the patient advocate of her meetings with family members, on the grounds that the notes are part of the professional-review process. An affidavit from Dr. Heit claims that even disclosing the names of staffers serving on credential or peer-review committees could prompt resignations from those secret bodies, putting the hospital in danger of losing its accreditation. “The risk of jeopardizing open, frank discussions and evaluations in peer review and credential evaluation is great if the names of the physician members of these committees are discoverable,” the affidavit states.
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The family’s attorneys have responded that hospital officials are seeking to conceal relevant facts in a “veritable black hole” of privilege. As for the “anonymous” doctors on the peer-review committee, a court filing notes that several of them can be identified through basic Google searches. The doctors list their participation in online résumés and bios, and at least one Centura hospital publishes its physicians’ committee memberships on its website.
In late July, Jefferson County District Judge Randall Arp granted the Farfan family’s motion to compel St. Anthony officials to turn over certain documents and divulge more information about what’s in the Mozia file that they insist can’t be shared. “Neither the quality-management nor peer-review privileges protect factual information from discovery,” Arp ruled, “simply because the information may have been considered in a quality-management or peer-review proceeding.”
A trial in the case is scheduled for next month. Valdez thinks about the daily phone calls he used to receive from his mother and looks forward to his day in court.
“There’s not a day that I don’t think about her,” he says. “I miss her voice, mostly. She had a very strong moral and ethical compass. She was a devout Catholic. That’s one reason she worked for this institution — and their mission statement goes in the face of what happened to her. Hopefully, this will get people to think about some changes that have to be made.”