Coleen Thompson

Case record: Coleen Thompson

Background

Coleen Thompson was a former intensive care nurse at Shady Grove Adventist Hospital. She worked in the hospital’s intensive care unit, a 26-bed adult intensive care unit, after being hired through a nurse staffing agency in May 2002 and beginning full-time work as a staff nurse at Shady Grove in August 2002.

Thompson later faced nursing-board action and job-related suspension and firing amid investigations into patient deaths.

The offence

Thompson pleaded guilty to five counts of second-degree neglect of a vulnerable adult, described as intentionally failing to provide medical care required by her job. Second-degree neglect of a vulnerable adult was described as “the intentional failure to prove necessary assistance and resources for the physical needs of a vulnerable adult.”

Prosecutors said there was no evidence to support a charge that Thompson deliberately killed the patients. Defense counsel said Thompson may have been negligent, but said it was linked to her being overworked in an understaffed intensive care unit; the claim was described as disputed by an attorney for Shady Grove Adventist. Defense counsel also characterized the matter as not a mercy-killing case, and said the patients were going to die anyway.

Investigation

A State Board of Nursing suspended Thompson’s nursing license in connection with the death of a 63-year-old female patient at Shady Grove; the patient’s name was not released. The nursing board accused Thompson of failing to follow proper procedures during a five-hour period before the patient’s death July 6. A hearing on the suspension was scheduled for Aug. 26. No charges had been filed at that time.

Police and hospital authorities investigated whether Thompson caused the death of one or more patients in the ICU. The hospital had also set up a hot line from 7 a.m. to 11 p.m. to provide support for those seeking it, and described contacting the national Joint Commission on the Accreditation of Health Care Organizations about the current case; the commission was reviewing it. The commission had placed Shady Grove on preliminary non-accreditation status three years earlier after its own review, and the hospital had been returned to full accreditation after a re-inspection.

Montgomery County police were described as conducting an around-the-clock investigation. The hospital informed the state’s attorney office of concerns July 10, and the office began an investigation. A state’s attorney declined to comment about the case.

In a nursing board report on Thompson’s suspension, the patient was described as a 63-year-old woman admitted to the ICU on July 1 and diagnosed with respiratory failure, streptococcal pneumonia, chest pain, abnormally low blood pressure, and septic shock. The patient was on a ventilator and receiving multiple intravenous medications when Thompson was assigned as primary nurse during the 7 p.m.-to-7 a.m. shift. The doctor’s orders were described as stating the patient’s blood pressure should be observed and kept under control, but the board found that when blood pressure dropped below the level specified by the doctor, Thompson repeatedly failed to take proper medical steps for almost five hours beginning at 8:30 p.m. The patient died at 1:10 a.m.

“There’s a standard of care that she should have been providing that she failed to provide,” said Donna Dorsey, the nursing board's executive director and a registered nurse.
“It appears she was watching that blood pressure, and when it got dangerously low, she didn't take appropriate action.”

During a news conference, Deborah A. Yancer and county Assistant Police Chief John King described Thompson’s actions as willfully contributing to the patient’s death and perhaps to others.

“An immediate internal investigation revealed that this concern was credible and, if true, constituted potentially criminal behavior,” said Yancer.

Arrest / suspension / employment actions

On July 17, 2003, the state Board of Nursing suspended Thompson’s license as police investigated whether she caused the death of one or more patients in the ICU at Shady Grove Adventist Hospital. The hospital also suspended her with pay pending the outcome of a criminal investigation, and no charges had been filed at that time.

Thompson was described as having been on paid suspension since a complaint was made against her July 9. The nursing board served her with notification at her home. No one answered when a reporter rang the bell at Thompson’s home.

The hospital fired Thompson “this week” after the suspension described in the July 17, 2003 report, and the hospital later fired Thompson in connection with its review. A spokesman Robert Jepson declined to elaborate, citing employee confidentiality. Thompson had been on paid leave while another nurse complained July 9 about Thompson’s care of a 63-year-old female patient.

Trial / plea

Thompson pleaded guilty in March 2005 to five counts of second-degree neglect of a vulnerable adult. On March 9, 2005, she pleaded guilty to five counts in a deal with prosecutors, with each count punishable by as much as five years in prison and a $5,000 fine. She was to be sentenced May 17. The Montgomery County State’s Attorney’s office agreed not to recommend consecutive sentences as part of the plea agreement.

The March plea was described as a guilty plea to five counts of second-degree neglect of a vulnerable adult. A judge asked Thompson whether she was pleading guilty because she was, indeed, guilty, and she answered “yes.”

“I was arrogant. I will admit that,” Thompson said in court.
“I thought I knew what was best for my patients. . . . But it was never malicious, it was never intentional.”

Defense attorney Philip Armstrong told the judge that prosecutors “didn't disclose [any cases] where her actions caused, contributed to or hastened the death of a single patient.” Armstrong also argued Thompson was overstressed because the hospital did not have an adequate nursing staff and stated some allegations came from another nurse described as “disgruntled.” Armstrong also said Thompson was the victim of a “media feeding frenzy” prompted by hospital officials holding a news conference in July 2003 about suspicious deaths.

“This is not a mercy-killing case,” Armstrong told reporters outside the courtroom.
“If it was a mercy killing, she'd be charged with murder. . . . The horribly callous but inescapable fact here is that all these people were going to die anyway.”

Sentencing

On May 17, 2005, a Montgomery County Circuit Court judge sentenced Thompson. At the sentencing hearing, the judge was identified as DeLawrence Beard.

Beard sentenced Thompson to 18 months on each count, then suspended all but 45 days. He also sentenced her to 18 months of supervised probation. The sentence was far less than the minimum of five years in prison sought by prosecutors. The maximum possible sentence described for the five charges was 25 years.

Thompson sobbed as she told Judge Beard that she was “extremely, extremely sorry for the pain and suffering that my nursing inadequacies caused” family members of the patients at the Rockville hospital.

Outcome

Thompson’s guilty plea resulted in a sentence of 45 days in jail after suspension of the remainder of the 18-month terms on each count, and she received 18 months of supervised probation.

Authorities said there was no evidence to support a charge that Thompson deliberately killed the patients.

Victims and alleged incidents (as described)

The case involved five patients who died while Thompson was working in the hospital’s intensive care unit in 2002 and 2003.

Listed victims

Court documents listed the five victims as:

• Harry L. Hancock, 69 (died July 5, 2003; five days short of his 70th birthday)
• Geraldine Baxter, 68 (listed as 68 in court documents; later described as 69 in a sentencing-day account)
• Lillian Vanzandt, 83 (later described as 82)
• Raymond H. McGivern, 86
• Adele Urbina (age could not be determined in one report)

Incident allegations described in the case proceedings

In one case described by Deputy State’s Attorney John McCarthy, Thompson did not notify a doctor when Adela (Adele) Urbina, 63, hospitalized with pneumonia experienced a sharp drop in blood pressure.

In another case involving 86-year-old Raymond McGivern, McCarthy said another nurse confronted Thompson about the fact that McGivern’s intravenous pump had been left repeatedly in the “standby” position. McCarthy said Thompson became upset that the other nurse would not turn off the pump and “allow the patient to die,” and that Thompson failed to give Lillian Van Zandt medicine needed to stimulate her heart.

McCarthy said another nurse suspected that Thompson had turned off the IV pump attached to 69-year-old Harry Hancock before a doctor pronounced him dead.

In the case of Geraldine (Geraldine Baxter), McCarthy said Thompson gave morphine that had not been ordered by a doctor, and declared Baxter dead 13 minutes before her last heartbeats were recorded.

The Maryland medical examiner’s office pinpointed the five cases in a review of 211 deaths during Thompson’s 14 months as an intensive care nurse at Shady Grove, McCarthy said.

Other details (named individuals, family, and related civil allegations)

Mary Swaim, 34, was identified as the granddaughter of Lillian Van Zandt, who died March 30, 2003 while in Thompson’s care. Swaim said she was “shocked and hurt” and described a hospital visit hours before Van Zandt died at age 82.

Philip Armstrong was Thompson’s attorney. Montgomery Deputy State’s Attorney John McCarthy outlined the cases for Judge DeLawrence Beard. State’s Attorney Douglas F. Gansler described why Thompson was not charged with deliberately killing the patients and stated authorities had found no evidence to support such a charge.

Relatives of the victims provided statements in the reports. Pauline Swaim, 61, and Ginny Householder, 59, were identified as daughters of Lillian Van Zandt. Householder said: “We said we wanted to see if Mom would get better, and we'd have to make that decision down the road,” and “I think she just had a problem in playing God.”

The allegations and discussions in reports also included civil claims and wrongful death litigation related to Thompson’s nursing practices, including a wrongful death suit filed July 2003 against Thompson. The record described a wrongful death dispute involving John Lieb, a cinematographer admitted to Shady Grove in critical condition with a bowel obstruction on Oct. 22, 2002. The incident described included morphine administration and discussions about removing a respirator. In that narrative, Lieb’s children said Thompson injected him with morphine via a “very large syringe” contrary to an order for slow administration in drops, and Thompson told the family “that he will pass away in the next half to one hour.” The narrative stated Lieb died early in the morning of Oct. 29 after being declared dead early in the morning.

In one civil context narrative, Robinson, who was described as Elizabeth A. Robinson, 33, said she and her family believed Thompson purposely hastened her father’s death, and they filed a wrongful death suit in July 2003.

The record also included information that Thompson’s nursing license had been suspended in July 2003 and that she was fired from her job at Shady Grove “several weeks later.”

Neighbors described Thompson’s home life. Peter Schroebel, 44, and his wife Joan were mentioned as neighbors. Schroebel said Thompson told his wife she worked at another area hospital before her employment with Shady Grove, and he described her as saying she had to find work about a month earlier without saying why. The record described Thompson as married with two children, including an infant and one about 5 years old.

Timeline

• July 16, 2003 — State Board of Nursing suspended Thompson’s nursing license in connection with the death of a 63-year-old female patient at Shady Grove; a hearing was scheduled for Aug. 26.
• July 17, 2003 — The Board of Nursing suspended Thompson’s license as police investigated whether she caused the death of one or more patients in Shady Grove’s ICU; the hospital suspended her with pay pending the outcome of a criminal investigation.
• October 22, 2002 — John Lieb was admitted to Shady Grove in critical condition with a bowel obstruction (civil litigation narrative).
• October 27, 2002 — Thompson told family members that Lieb’s condition had taken a grave turn and pressed them to decide whether to remove him from the respirator (civil litigation narrative).
• October 28, 2002 — Lieb’s children made the decision to stop use of the respirator; morphine administration via drip was ordered (civil litigation narrative).
• October 29, 2002 — Lieb was declared dead early in the morning of Oct. 29 (civil litigation narrative).
• December 13, 2004 — Thompson was scheduled to plead guilty to second-degree abuse or neglect of a vulnerable adult (court documents narrative).
• March 9, 2005 — Thompson pleaded guilty to five counts of second-degree neglect of a vulnerable adult; sentencing was set for May 17.
• May 17, 2005 — Judge DeLawrence Beard sentenced Thompson to 18 months on each count, suspended all but 45 days, and imposed 18 months of supervised probation.