Loretta Shaver doesn’t want to remember her mother, Terry Smith, as the woman whose death might have been avoided at Bakersfield Memorial Hospital.
She prefers remembering her for who she was: the energetic 53-year-old jokester who played practical jokes and could spin a yarn. The one who spent the last year of her life caring for her 14-year-old son, despite struggling with a brain tumor.
When Shaver read headlines last week about the state fining Bakersfield Memorial Hospital $75,000 after an investigation revealed nurses failed to provide adequate supervision to a patient who choked to death, who Shaver said is her mother, her reaction was succinct.
“This means justice for my mom,” Shaver told The Californian. “And maybe for a lot more patients that this could happen to.”
The California Department of Public Health would not confirm the patient at the center of the investigation was Smith, citing patient privacy concerns. Shaver, however, provided her mother’s death record, which shows that she died at Bakersfield Memorial on March 15, 2016, of cardiopulmonary arrest as a result of aspiration of food – the same cause and date of death described in the report.
Bakersfield Memorial self-reported the incident to the CDPH and developed new policies, revised processes and protocols and re-educated staff and physicians to ensure similar incidents don’t occur again, hospital officials said in an emailed statement last week. A hospital spokesperson said it stood by its statement Tuesday.
When Smith checked into the hospital, it was to relieve some pressure from her temple. She had been suffering severe headaches, and had lost most of her vision the last two years of her life, Shaver said.
Shaver, who admits she had a strained relationship with her mother, was 18 at the time and living with her grandparents in Corcoran. Her father drowned in the Kern River in 2001 when she was just 4 years old, she said. At 18, just a couple months away from graduation, she was left to contend with her mother’s death, which she said was preventable.
There were multiple warning signs documented in the state’s report. Nurses and an occupational therapist noted the patient was eating too fast and was in danger of choking. A speech-language pathologist recommended she have a “mechanically soft diet,” to make food easier to swallow. A doctor required somebody be present as she ate.
That last order wasn’t followed. Smith choked, and nobody was there, according to Shaver. She went into cardiopulmonary arrest as a result, Shaver said.
“The nurse who was supposed to be watching my mother found her 45 minutes after she choked,” Shaver said. “She did not find her choking. She found my mom dead.”
Smith was placed on a respirator and kept alive for three days.
“‘What do you mean that she’s not going to wake up?’” Shaver said she recalls thinking at the time.
For three days, she was lying in a hospital bed, twitching, and then, “losing every little bit of anything she had,” Shaver said.
“You can’t really wrap your brain around the fact that she’s here, she’s breathing, but you can’t save her. Then you have to explain to your 15-year-old brother that no matter if she’s breathing or moving that she’s not coming back,” Shaver said.
Shaver took some time off to plan her mother’s funeral, then went back to school and graduated, she said. It’s taken her months to get past the anger from that day.
“At first I was really angry, especially with the nurse … she let my mother die,” Shaver said. “But it was not only the nurse’s fault, but it was the hospital’s fault for not monitoring the nurse. They all failed to do their job.”
Despite her storied end, Shaver tries to remember the life her mother led, instead of the way she died.
Smith had a maternal instinct, and cared for everyone around her, Shaver said. When she was walking down the street, it was hard for her not to smile at passersby and strike up conversations.
She loved the spotlight, and playing practical jokes.
On one occasion, she spotted her brother asleep, a feather pillow beneath his head. Smith scooted a portable heater beside it, not knowing, however, that it would burst into flames, Shaver said, retelling one of her favorite stories her mother shared with her as a child.
“There were feathers everywhere,” Shaver said, laughing. “The way she told that story was just so funny. I could never tell a story the way she did. She would have everyone captivated by what she was saying.”
If there’s any comfort Shaver takes in her mother’s passing, it’s that she didn’t die in vain. Her death triggered a state investigation and reforms within the hospital, which could save lives in the future.
Notwithstanding, her mother already has saved at least three others.
She was an organ donor.