Death in Illinois ER Ruled a Homicide

CNN: Death after two-hour ER wait ruled

WAUKEGAN, Illinois (AP) — A coroner’s jury has declared the death of a heart attack victim who spent almost two hours in a hospital waiting room to be a homicide.

Beatrice Vance, 49, died of a heart attack, but the jury at a coroner’s inquest ruled Thursday that her death also was “a result of gross deviations from the standard of care that a reasonable person would have exercised in this situation.”

Vance had waited almost two hours for a doctor to see her after complaining of classic heart attack symptoms — nausea, shortness of breath and chest pains, Deputy Coroner Robert Barrett testified.

She was seen by a triage nurse about 15 minutes after she arrived, and the nurse classified her condition as “semi-emergent,” Barrett said. He said Vance’s daughter twice asked nurses after that when her mother would see a doctor.

When her name was finally called, a nurse found Vance slumped unconscious in a waiting room chair without a pulse. Barrett said. She was pronounced dead shortly afterward.

(emphasis added)

Chest pain triaged to the waiting room is really not a good idea.

The Chicago Tribune adds a little to the ‘what happened next’ question:

Vance was seen by a triage nurse at 10:28 p.m. According to hospital records, she complained of nausea, sweating and chest pain of a level she rated as a ’10, with one being the lowest and 10 being the highest,’ Barrett testified. ‘The triage nurse classified her condition as ‘semi-emergent,” he said.

At 12:25 a.m., an emergency room nurse went to the waiting room and called for Vance, but got no response, he said. Vance was leaning on her side on a waiting room seat, unconscious and without a pulse.

Doctors rushed her into the emergency room, administered CPR and put Vance on intravenous blood thinners, Barrett said. At about 12:55 a.m., doctors were able to generate a weak pulse. About 10 minutes later, the pulse stopped and doctors restarted CPR. Vance was pronounced dead at 2 a.m.

No decisions have been made about criminal charges, yet, according to the articles.

FindLaw has a copy of the Coroner’s Jury Verdict form.

Thanks to reader Andy for the tip.


  1. I absolutely agree that chest pain presenting with nausea is absolutely a case for coming straight on back to the ER. I just have to wonder what the situation was in the rest of the ER. If it had been me, I’d have cleared a room for the patient if need be. Just wonder if they were out of stretchers and chairs, out of monitored beds, out of space, out of resources, was the staff completely tied up with multiple traumas? That kind of thing.

    I’ve worked where the difference between a good day and a bad day is defined as whether all the hall stretchers are lined up head-to-toe or side-to-side. I’ve seen people jumping over people lying in the floor because it was so overcrowded to get to one to code them. And there is a regional trauma center I know of that stays so overcrowded that sometimes patients do suffer heartattacks and die in the lobby. There is just so much O2 to be had, there are just so many crash carts, just so many monitors, just so much staff. I’m too old for that now, and too concerned about my license to deal with it anymore.

    I don’t know if the cause of this was an idiot nurse or a broken system. Either one is tragic. But I do hope people begin to realize that hospitals are bottomless pits of resources. There is a limit.

    I’ll be watching this story.

  2. Ooops, I re-read my comment – meant to say, hospitals are NOT bottomless pits of resources. I find that people believe that they are.

  3. Truly this is asinine. Not the case itself — it’s a tragic screw-up. One would presume the patient’s chart must have just gotten lost, because otherwise there is no excuse for not at least getting an ECG for starters. . .

    But that’s not the point. The coroner (and/or the jury) overstepped their bounds calling this a homicide. The cause of death is myocardial infarction caused by acute coronary thrombosis. That is a NATURAL cause of death. If the circumstances of her death involved medical malpractice and/or criminal negligence, that is a decision for a prosecutor, judge, and jury. Not for the coroner.

  4. shadowfax, legally, the coroner IS the first step in the prosecutor-judge-jury cycle. effectively, the coroner is the triage nurse of the legal system, responsible for deciding only whether your case gets in the door, not what the treatment will be.

  5. Steve White says:

    I’m an academic doctor in Illinois. If one goes to the ‘about’ page of the hospital’s website, one will see that the hospital has modern cardiac cath facilities and a modern emergency department.

    When a patient comes in with 10 out of 10 chest pain, nausea and shortness of breath, that triad screams ‘MI!!” to good ER nurses and doctors. Such a patient moves immediately to the head of the line, and appropriately so.

    We (the medical profession) know that prompt treatment with nitrates, oxygen, clot-dissolving drugs, beta-blockers, and aspirin substantially reduce the immediate risk of death. We also know that if the hospital has a cardiac cath lab, getting the patient there within the first two hours of presentation for diagnosis and treatment of the coronary blockage reduces mortality further.

    This episode has me shaking my head in disbelief. I don’t know whether it’s properly a ‘homicide’, but a horrific blunder? Without question. However, having the medical examiner involved is proper — whenever there is a suspicion concerning a death, having the ME involved will lay to rest concerns that could be raised later about ‘cover-up’ and so on.

  6. I believe there are two aspects to this story to be considered:
    1) the failure to provide immediate care given the symptoms (already discussed in other posts) and 2)the “unprecedented” homicide ruling. I read on the coroner’s website that the jury is made up of 6-7 county residents who must make a decision based solely on the deputy coroner’s (Barrett) testimony. Additionally, the jury report (available on CNN) shows only four possible rulings. Something is amiss.

  7. Chest Pain, nausea, shortness of breath. From my experience with a family member, call 911. Do not go to the ER on your own. Ambulance arrival at a hospital receives far more scutiny and attention (higher triage level) than any walk in. As for homicide, this just doesn’t seem to fit. Tragic, yes. Negligent, possibly. Homicidal, a big strech.

  8. All pain is 10/10 in triage, isn’t it?

  9. Supremacy Claus says:

    Perhaps, this error is a homicide. The 20% of innocent people on death row, after months of trial and appeals, $1 million in legal costs, then qualifies for homicide by all parties involved.

  10. funky chicken says:

    Do you think if this patient had been male the MI symptoms would have gotten more attention? I’ve read that women’s heart disease often goes undiagnosed.

  11. 20%? No way.

    I wondered about gender bias and chest pain, too, when I read the article. I have to think the triage nurses’ defense will be ‘I thought it was GI”, which isn’t much of a defense but is more common in this age group of women than heart disease.

  12. gone in 60 seconds says:

    Triage, of itself, has become another wall between the patient and medical care. 30 years ago there was none and people weren’t dying in ER waiting rooms. As additions are made to the process of emergency care, patient care is diminished, especially on the time line. Basically, medical care in ER is going south. In fact, the quality of the facility seems to be inversely proportional to the quality of patient care. With more money for facilities brings more process and more process brings lower quality patient care.

  13. Gone in 60 seconds, wow. But here’s what you’re missing: 30 years ago people weren’t showing up in ERs for primary care, ERs weren’t overflowing with narcotics addicts and drama queens (at least as much as they are now) and they weren’t utilizing it as the “Bargain Basement” of healthcare. Shoot…30 years ago “healthcare” was two words, not one, and we didn’t live in such a litigious society where people have to double & triple cover their asses. We also had a lot fewer drive-by shootings drug deals gone bad. Society wasn’t ideal but it wasn’t nearly as violent and “entitled” as it is now. All this contributes to ED conditions that will, tragically, sometimes allow a truly sick individual to fall through. It is hard for me to fathom that the triage nurse sent this patient back to the waiting room but I am still wondering what the conditions behind those ED doors were at the time and if they genuinely had the physical and personnel resources available to handle another potentially critical patient at that moment. I absolutely agree that the very same processes that people put into place to ensure quality defeat that very purpose, particularly in a fast-paced truly emergent situation. I also think we have a much larger crisis on our hands simply due to modern society and this kind of thing can be a symptom of it. If so, I hope that this opens peoples’ eyes.

    Also wonder if the patient involved was a known drug-seeker. Cry Wolf Syndrome and all that. No excuse if that’s the case, but it could make more sense….

    And if everything was fine and that nurse was truly negligent, then let her hang.