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January 1, 2013

To: Florida Governor Rick Scott

Re: Open Government Request for Information

Florida Board of Medicine

Agency for Health Care Administration

Sentinel Event of my husband at Tampa General Hospital resulting in death.

September 28, 2011

Dear Gov.

Are you and The Florida State Board of Medicine appointees as interested in insuring that Tampa General Hospital is worthy to be an accredited institution as I am; regarding the statement claims of being on a mission to protect and promote health of the public? I’d like to know what have they or are they doing to identify and or improve upon the risk management root cause factors that will be judged in the court system regarding the sentinel event death of my husband on August 23, 2010 at Tampa General Hospital. I am requesting an Open Government Agency request for documentation regarding this case specific area of hospital oversight policies, whether it is admissible as evidence or not. Will you accept this request in my quest for accountability and the recording of what is the truth in this matter?

I am requesting the statistics of how many Sentinel Events resulting in death or brain injury were reported by Tampa General and subsequently investigated by survey of the Agency for Health Care Administration at Tampa General in 2010 and all associated decisions rendered by the Agency for Health Care and the same for 2011 to date. And if any patient complaints were received regarding bed lift teams for the same time periods and what measures or changes have been implemented to date if any.

I am aware of the recent  report of the Joint Commission’s mock survey done at Tampa General Hospital and the recurring accreditation issues it revealed, as well as some of the Administrative Law  cases  published on the DOH website regarding complaints. TGH may be concerned about the public’s perception and their reputation as their representative stated publicly in those documents, but I am concerned about the apparent total failure of their risk management system; which the non- medical trained public such as myself and especially MY HUSBAND relied on when entering an accredited  hospital. Naturally assuming that basic standards of care are  part of  planning and oversight built into such a well established and monitored system with any necessary backups in place to insure there is no breach in critical care delivery to patients; especially in a facility that is operating at a profit and could expend more financial resources where needed if shown necessary to insure the public safety in known areas of  concern. Is Tampa General operating at a deficit and does that have any bearing?

The court will soon have the opportunity to hear about my husbands trip to TGH, which resulted in the cutting short of his time that is; if as the only survivor eligible to bring this case; I don’t die before it comes to a conclusion, due to the Florida statutes of eligibility.  And just in case that should happen as there is no other legal recourse left for me to stand in the gap for my beloved husband regarding what happened to him at TGH, I request that you  personally look into this issue and give it the extra attention necessary to remedy in advance of a court ruling on the matter ASAP and insure any improvements recognized as necessary to the system are made immediately for everyone’s well being and protection. My husband no longer is around to provide my protection and he cannot speak for himself or others so I am doing it for him in process of being appointed his personal representative for this case. Are you ready willing and able to respond to my requests for information? Please reply you have received this transmission and what your intentions are regarding a timeline of responding to it if any.

My husband was a living legend and I am a grieving and outraged widow who wants to know if the Agency for Health Care Administration has looked into and already conducted a survey into the sentinel event death of my husband and if so when did it take place?  And did TGH report it to the Agency for Health Care and did they investigate it themselves and when  did they finish their own internal investigation?

Had I not observed a negligent and traumatic and possibly what will be considered an adverse incident during the bed lift team’s  handling of my husband; while using an overhead lift to move him in ICU, that I initially thought was the reason and main cause that contributed most to his death; perhaps this apparent total system failure of the TGH risk management program pertaining to his case and possibly others would not even have become known, as pertaining to the other more foundational standard of care or potentially provable deemed acts and omissions that have been revealed, through the expert witness testimony that has come forth to date while pursing the truth, of what really went wrong in this case.

I’d also like to know if this potentially determinable adverse incident, of the inverted downward head position bed lift that I witnessed  that I told numerous TGH staff about my concerns for the affect it had on my husbands condition when it occurred; was found in any Agency for Health Care Administration survey report investigation that may have already been conducted regarding this case and was an incident report made to any TGH risk manager by any of the TGH staff who witnessed it or were involved in it. Many were told of its occurrence and as no one I told would comment or respond regarding my verbal complaints and concerns of how this would be affecting his condition and no one came to inform me of any additional damage or injury that was likely to result is there even a record of it? Perhaps the agency was able to determine if any incident reports were made by any of those staff that I reported this to or by the attending witness’s of the actual event and I am requesting this Agency for Health Care information as well.

This aspect of the case is not yet been added or requested for discovery but I am determined that it shall be. This is more than a legislative topic for me and a well known area of concern regarding safe patient handling. I’d really like to know what the risk management program for bed lift teams in ICU is over at TGH and what steps they may have already taken to insure another critical patient is not subject to more potential damage from already life threatening factors.

I understand that some of these internal reports are not available to the public  or admissible as evidence in court so what can you say to me or are you willing and able to do regarding my intentions to see the truth revealed and recorded regarding my requesting all the information contained in the body of this letter? How open is this government really when some pertinent records are not publicly available in Public Health law as listed in Chapter 395 regarding hospital Licensing and Regulation? Is all or some of this information requested a secret and to be withheld from the public including me or will your office respond to my request?

Deborah A. Krekic  PERSONAL REPRESENTATIVE of Herman Krekic

Rochester NY 14612

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