A wrongful death trial underway in Fresno County Superior Court will determine whether Saint Agnes Medical Center staff and a doctor were negligent in the November 2014 death of a retired school teacher who was seeking treatment for ovarian cancer.
Patricia Astone was a special education teacher, master gardener and deacon at Sanger Community Church. In August 2014, she was diagnosed with late stages of ovarian cancer.
Determined to beat the disease, the 73-year-old Astone began chemotherapy treatments and underwent cancer-removal surgery at Sequoia Hospital in Redwood City in October 2014.
Astone began feeling optimistic when her doctor told her that the operation was a success and that with continued chemotherapy she could be cured or her cancer could go into remission, Fresno attorney Daniel Baradat says in court papers.
But she began deteriorating soon after she went to Saint Agnes for chemotherapy treatments in November 2014, court records say. After a few days of chemotherapy, Astone was discharged from Saint Agnes on Nov. 5, 2014. Three days later, she began vomiting and complaining of pain.
Her husband, Robert Astone, called oncologist Dr. Rabia Parveez of California Cancer Care Associates for Research & Excellence, or cCare, who told him to take his wife to the emergency room of Saint Agnes, court records say. Hospital staff did all they could to save her, says Fresno attorney Jerry Casheros, who is defending Saint Agnes.
By all accounts the Astones were a good family and they had a strong marriage.
Fresno lawyer Jerry Casheros
But in the early hours of Nov. 12, 2014, Patricia Astone died from septic shock with aspiration pneumonitis, court records say.
Following his wife’s death, Robert Astone, 78, sued Saint Agnes staff and Parveez for negligence and medical malpractice. Baradat, who represents Astone, contends in court papers that the “defendants failed to diagnose and treat a urinary tract infection in Mrs. Astone, which led to acute septic shock from which she died less than a week after she was admitted to the hospital.”
Robert Astone is seeking damages for medical malpractice, which is capped at $250,000 by the Medical Injury Compensation Reform Act of 1975. He also seeks money for funeral expenses and for loss of his wife’s pension.
The trial in Judge Alan Simpson’s court should wrap up in one to two weeks.
Key piece of evidence
Already, jurors have seen a key piece of evidence: a letter written by Saint Agnes risk management director Julie Cade to Robert Astone. The Dec. 9, 2014, letter says: “As a result of our investigation, we recognize there were missed opportunities to identify and treat your wife’s condition sooner; we are currently evaluating our processes around sepsis management to determine how we can make improvements …”
In court papers, Baradat contends the letter is clear admission by the hospital of being liable for Astone’s death. But Casheros, the lawyer for Saint Agnes, says in court documents that the letter is hearsay because Cade had no first-hand knowledge of the medical care given to Astone, so therefore “such retrospective analysis is of no relevance to the court in a medical malpractice case.”
In addition, Casheros contends the letter does not constitute an admission of liability. “In every case where a diagnosis is not made, a health care provider can go back and determine ‘missed opportunities’ to have made the diagnosis,” he says in court papers. “As the court knows, just because a diagnosis was not made does not equate to negligence.”
We recognize there were missed opportunities to identify and treat your wife’s condition sooner.
Saint Agnes risk management director Julie Cade in a letter to Robert Astone
In his lawsuit, Astone blames Saint Agnes nurses, not the doctors, and Parveez, who is not employed by the hospital but has privileges to practice there. At the time of the incident, Parveez was covering for Patricia Astone’s primary oncologist, Dr. Joseph Pascuzzo. Parveez is represented by Fresno attorney Dirk Paloutzian.
Robert Astone has an unusual ally – his ex-wife’s husband, Dr. Bjorn Nilson, who has testified that he called Saint Agnes on Nov. 10, 2014 and talked to staff. Once he learned Patricia Astone’s blood pressure was dropping, Nilson testified, he told staff to get Patricia Astone into the intensive care unit because she was going into shock.
Nilson also told jurors that he went to the hospital the next day to make sure that Patricia Astone was receiving proper care. He testified the treatment provided by Saint Agnes nurses and by Parvez to Patricia Astone was below medical standards of care.
After her death, Nilson testified that he tried to find out what happened, but he testified that hospital staff either lied to him or “had selected amnesia.”
“She was deteriorating in front of them for three days,” Nilson told the jury. “If a patient died on my watch I would not forget what happened.”
Knock on credibility
But Casheros told the jury the 77-year-old Nilson lacks objectivity because he is married to Robert Astone’s ex-wife and helped raise Robert Astone’s two children. Though Nilson questioned nurses and physicians, he was a pediatrician who retired in 2006 and has not seen a patient in a hospital for at least a decade.
In defending Saint Agnes and Parveez, Casheros and Paloutzian plan to call experts who are board-certified in internal medicine and critical care medicine. Though Nilson says in his deposition before trial that he was board-certified, Nilson admitted on the witness stand that he no longer was board-certified and that he helped Astone find a lawyer to sue Saint Agnes and Parveez. “Our goal was to make sure it didn’t happen to someone else,” he testified.
Despite his lack of credentials, Nilson told the jury that he still believes Saint Agnes and Parveez are negligent in Astone’s death and are trying to avoid responsibility. “They’re circling the wagons and don’t want to admit their mistakes,” he testified.
The events leading to Patricia Astone’s death are described in trial briefs filed by Casheros and Baradat. During the trial, jurors have been getting a crash course on medical terms such as electrolyte imbalance (body fluid loss), debulking (surgical removal of a tumor) and intraperitoneal port (in which chemotherapy can be administered directly into the abdominal cavity).
In his brief, Casheros expresses sympathy for the loss of Astone’s wife. “By all accounts the Astones were a good family and they had a strong marriage.” Casheros says.
Her final days
The two briefs give similar accounts to what happened, but Baradat’s concludes what allegedly went wrong:
When Astone was admitted to the emergency room, Dr. Richard Winters diagnosed her with “dehydration, urinary tract infection and electrolyte imbalance.” Winters ordered lab tests for Astone and spoke with Parveez by telephone about admitting Astone as a hospital patient for nausea, vomiting, diarrhea, dehydration and low potassium.
Within four hours, a urine test showed that Astone had an infection. A more detailed urinalysis culture that came on Nov. 9, 2014, was positive for E-coli. “Despite evidence of infection, no antibiotics were given to Mrs. Astone,” Baradat says in his brief.
If a patient died on my watch I would not forget what happened.
Retired Fresno doctor Bjorn Nilson
When Parveez saw Astone on Nov. 9, 2014, she failed to review the emergency room record or the lab results from the urinalysis, nor did she give her antibiotics, Baradat says.
Parveez saw Astone on Nov. 10, 2014, but again no antibiotics were administered to Astone, Baradat says. Astone’s temperature spiked later that afternoon. Parveez ordered an antibiotic and Astone received the medicine that night. Astone’s condition continued to deteriorate with low blood pressure, abdominal pain and increasing shortness of breath, Baradat’s brief says.
She was lethargic, confused and had tachycardia, a heart rate that exceeds the normal resting rate. She was admitted to the Intensive Care Unit “with acute septic shock,” Baradat says.
On Nov. 11, 2014, Astone’s condition worsened. Dr. Juan Chavez performed an endotracheal intubation, in which a plastic tube is inserted into the trachea (windpipe) to open her airway. But Astone’s stomach contents were not evacuated before the breathing tube was inserted, “which caused her to aspirate vomit into her lungs and asphyxiate,” Baradat’s brief states. “This caused Mrs. Astone’s heart to stop.”
It took six to seven minutes for doctors to re-establish Astone’s heartbeat, Baradat says. Astone died around 4:40 a.m. the next morning.
In his brief, Baradat blames Parveez because she had access to Astone’s emergency room medical records but admits she did not know that a urinalysis test and culture had been done, “nor did she know they were positive for infection.” Parveez also delayed in giving Astone antibiotics to fight off the infection, Baradat says.
In addition, Baradat says in his brief that Astone’s autopsy revealed she had no cancer following her surgery to remove it.
But Casheros says in his brief that Astone likely would not have survived another five years, given her age and her ovarian cancer. He and Paloutzian contend in court documents that Saint Agnes staff and Parveez did all they could to save her life and that their medical experts have thoroughly reviewed the case and conclude that neither Saint Agnes nor Parveez are liable for her death.