State report: Breathing tube error killed Minneapolis nursing home resident

For decades, Bruce Peck made a living in the Twin Cities as a family law attorney, talking to adversaries about how it was better to get along than to battle it out in court.

But throat cancer and other maladies left him in a Minneapolis nursing home virtually unable to speak because of the tracheotomy tube that fed his lungs with oxygen. A doctor's order allowed him to try to breathe on his own, an accomplishment that would mean uttering no more than a few words at a time.

That test came to a deadly end, however, when a nurse's mistake with the tube cut off Peck's access to oxygen, a state investigation determined.

Within 15 to 30 minutes, Peck, 75, suffocated in his room at the Benedictine Health Center.

A Minnesota Department of Health investigation blamed not only the licensed practical nurse for the Nov. 14 death, but also the care facility for failing to adequately train the employee on the use of a tracheotomy tube after her monthslong leave of absence.

In response to Peck's death and the investigation's finding of neglect, released Tuesday by the Health Department, the nurse was suspended by the nursing home immediately after Peck died and remains off the job. The health center also put nurses through retraining in this area of care within 48 hours and required they demonstrate competency.

The Benedictine Health Center is in the Elliot Park neighborhood on the southern edge of downtown Minneapolis. It is part of the Duluth-based Benedictine Health System, which is sponsored by the Benedictine Sisters of St. Scholastica Monastery in Duluth and offers senior care elsewhere in Minnesota as well as in Illinois, Missouri, North Dakota and Wisconsin.

Specifically, the investigation determined, the nurse capped the breathing tube attached outside Peck's neck. This action was intended to allow him to breathe through his nose and mouth.

However, the nurse left the room having failed to deflate the cuff that wraps around the tube and holds it in place, thereby blocking oxygen from entering Peck's lungs.

When the nurse returned to the room about 15 minutes later, she found Peck slumped over and unresponsive in his wheelchair.

"She said she called out for help and did not know what had happened to the resident," the investigative report read.

Peck had suffocated within 30 minutes from what the Hennepin County Medical Examiner's Office described as "inadvertent cuff inflation."

In the United States, a 2012 survey of head and neck surgeons estimated there are about 500 tracheotomy-related deaths per year in this country.

"Capping the trach was the last step," Peck's daughter, Robyn, said Wednesday. "If he could tolerate that, they'd be able to remove the trach. But now there's an accident, and he's dead."

His daughter said the tracheotomy was especially burdensome for Peck, whose ability to speak was vital in his long career as a family law attorney, because "he was only getting out a few words at a time."

"He was cognitively all there. He knew what was going on around him, but he couldn't communicate" verbally because of the tracheotomy, she said.

Peck, who grew up in Fairmont, Minn., and earned his law degree from William Mitchell in St. Paul, founded the Collaborative Law Institute of Minnesota, whose mission is to keep divorcing clients from having to go to court to settle differences.

"He helped people move through a difficult time without hurting each other. He was really good at that."

That work-it-out spirit served him well despite coping with his throat cancer and other medical problems that preceded his move from his home in Burnsville to the nursing home.

"What was amazing was that he kept smiling," his daughter said. "He really did an amazing job making the best of the situation he was in and not taking it out on the people around him."