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Continued: At military hospitals, chronic errors and lax oversight plague care

  • Article by: SHARON LAFRANIERE and ANDREW W. LEHREN , New York Times
  • Last update: June 28, 2014 - 9:41 PM

Communication issues

When patients die unexpectedly, medical workers often cite a breakdown in communications.

Katie Guill checked into the hospital at Fort Leonard Wood, Mo., on Christmas morning 2008, expecting to give birth to a healthy baby boy. She left with an infant so severely brain-damaged that at age 5, he cannot crawl, speak or swallow. He is fed through a pump.

In the three hours before a doctor finally delivered their son, Justen, by Caesarean section, the Guills said in a lawsuit, a monitor sounded 32 alerts that the baby’s heart rate had slowed. The suit also said the nurse had warned the doctor on duty four times that the baby was in distress before he arrived at her bedside.

The government settled the case for $10 million, but Pentagon records give no indication that a safety investigation was conducted. Nor is there a record of any action against the doctors and nurses involved.

“We don’t know what went wrong because no one has ever told us,” said Justen’s father, Jon Guill, who served 18 months in Iraq.


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  • Shelley Amonett looked at photos of her daughter, Jessica Zeppa, who was married to a soldier. Zeppa suffered a miscarriage and died in 2010 of complications from severe sepsis after being sent home from Reynolds Army Community Hospital four times.

  • Jon Guill, who served in Iraq, prepared formula for his son, Justen, who was born brain-damaged at a military hospital after prenatal distress allegedly went unaddressed, in Elgin, Okla., May 16, 2014. Internal documents obtained from military hospitals depict a military medical-care system in which scrutiny is sporadic and avoidable errors are chronic. (Brandon Thibodeaux/The New York Times)

  • Justen Guill, 5, above, born brain-damaged at a military hospital after prenatal distress allegedly went unaddressed, was held by his mother. Below, Jon Guill, who served in Iraq, prepared his son Justen’s formula.

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