After learning her son, Jason Cruz, had been in a car accident, Lillian Latimer rushed to his bedside at Staten Island University
Hospital. There, she found him with a breathing tube in his nose and a surgical trauma team ready to repair the fracture to
his left arm.
The hospital's medical staff reassured Latimer that her son's injuries were not life-threatening. Later that day, however,
Latimer was stopped by a member of the hospital's medical team and told that he had slipped into a coma. He died nearly three
weeks later.
State orders policy changes at hospital
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Cruz's family was devastated. For months, they wondered how the healthy, 28-year-old construction worker could slip into a
coma and die from a broken arm. Though they had no proof, they suspected Staten Island University Hospital was at fault.
The New York City Medical Examiner's Office and New York State Department of Health recently confirmed the family's suspicions.
Cruz, the father of a five-year-old girl, died from an overdose of fentanyl, a painkiller used most often in operating rooms
and on critically ill or injured patients. The medical examiner's office determined the overdose to be accidental and said
Cruz died from anoxic encephalopathy—a shortage of oxygen to his brain—triggered by acute fentanyl intoxication. "The dosage
he was prescribed was not the dosage he received," said Ellen Borakove, spokeswoman for the medical examiner's office. The
dosage he received was five times the prescribed dose, according to the results of a New York State Department of Health investigation.
Cruz received the excessive amount of fentanyl for 23 minutes, the investigation revealed. "Fentanyl is a very potent narcotic," said Michael Cohen, R.Ph., president of the Institute for Safe Medication Practices
in Huntingdon Valley, Pa. "With the injectible, the dose is measured by microgram and it often gets confused with milligram.
"
The lethal dose
Cruz was wheeled into the emergency room of Staten Island University Hospital (SIUH) after crashing his SUV into a brick wall
and steel guardrail on the morning of Jan. 19. He was given 40 mcg/min of propofol (Diprivan, AstraZeneca) and transferred
to the hospital's surgical intensive care unit, according to the state investigation. Later that afternoon, a surgical resident
ordered that Cruz be given 4 mcg/hr of fentanyl. The resident also prescribed Cruz a one-time dose of 50 mcg of fentanyl,
to be given through an IV pump, the state investigation concluded.
A nurse discontinued the propofol, and early that evening, the surgical resident wrote an order to discontinue the fentanyl,
state health documents show. At 6:40 P.M., nurses reported that Cruz was alert and responding to commands, but less than an
hour later, he was unresponsive, his heart rate had slowed to less than 60 beats per minute, and the oxygen levels in his
blood were dangerously low. A nurse restarted Cruz's dose of fentanyl at 6:54 P.M. without an order, and mistakenly gave him
20 mcg/hr for 18 minutes.
After Cruz died, the hospital offered to help pay for his funeral. The gesture, however, hasn't deterred Cruz's family from
moving ahead with plans to file a wrongful-death lawsuit against SIUH. John G. O'Leary, a Staten Island attorney representing
Cruz's family, did not return repeated phone calls for comment on the status of the lawsuit. John Demoleas, a spokesman for
SIUH, declined to comment on the pending lawsuit or circumstances surrounding the overdose, saying, "It's a tragedy and our
heartfelt feelings go out to the family, but we are not discussing the case whatsoever."
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