Two Los Angeles County prosecutors unsuccessfully sought a grand jury investigation in 2005 into deaths at Martin Luther King Jr./Drew Medical Center, igniting a behind-the-scenes debate about whether alleged misconduct merited a wide-ranging criminal investigation.
The prosecutors’ recommendation, which was outlined in a confidential April 8, 2005, memo, grew out of frustration with the slow pace of their inquiry into two patient deaths. In particular, they cited trouble obtaining hospital records and the county coroner’s removal of autopsy findings that suggested substandard care by King/Drew nurses.
The memo, which was recently obtained by The Times, went on to propose a broad look by a grand jury at the King/Drew deaths, possible cover-ups of misconduct at the hospital and whether the coroner was properly examining deaths involving medical wrongdoing.
Senior officials in the county district attorney’s office said they rejected the request because no specific crime had been alleged and problems at the troubled hospital were best addressed by county leaders.
Two years later, strong feelings persist on both sides of the debate. The senior prosecutor behind the recommendation said he wonders how many lives might have been saved at King/Drew had the district attorney acted aggressively.
King/Drew, now known as King-Harbor, faces possible closure because of continued lapses, including a recent high-profile death in the emergency room.
The district attorney’s office began a preliminary inquiry into two deaths at King/Drew in January 2005 in response to a written request by county Supervisor Zev Yaroslavsky.
“These two incidents cry out for a review of whether any of the involved personnel bear criminal responsibility for their conduct,” the supervisor wrote at the time.
In both cases, nurses were alleged either to have ignored patients’ heart monitors or failed to ensure that they were audible.
The D.A.’s office assigned the matter to a deputy prosecutor, Vesna Maras, who was then handling medical-legal matters. Working with state regulators, she accumulated thousands of pages of records.
In an interview, she said she determined that a broader investigation was needed to understand what was happening.
Among other hurdles, Maras wrote in the 2005 memo, county Chief Medical Examiner-Coroner Dr. Lakshmanan Sathyavagiswaran ordered the removal of part of an autopsy report on a patient who died at King/Drew on Nov. 18, 2004.
According to Maras’ memo, deputy medical examiner Dr. Louis Peña had found that “there was a failure to provide the most basic nursing or medical care” to a 47-year-old patient who died. But the coroner deleted that opinion and ruled the manner of death “undetermined.” (The memo refers to the patient as Jane Doe; her name was Sandra Sagastume.)
Summarizing her concerns, Maras wrote, “It is not possible, in my opinion, to do an honest evaluation of those cases without simultaneously examining the coroner’s conduct.”
Doyle said he did not believe that the coroner’s office did anything wrong. Defining cause of death is the coroner’s job, he said, not the district attorney’s.
In an unusual turn of events, the memo surfaced this week during the trial of Phil Spector, the music producer who is accused of murdering a woman in his Alhambra home in February 2003. Prosecutors gave Spector’s defense team a redacted copy of the memo because Peña was the deputy medical examiner who performed the autopsy of Lana Clarkson and testified about it in court. The judge in the trial, Larry Paul Fidler, said the document was irrelevant and could not be raised.