Michael J. Barkley 161 N. Sheridan Ave. #1 Manteca, CA 95336 209-823-4817 July 8, 2006 Ms. Denise Ramirez, Ombudsman Kaiser Foundation Hospital 2025 Morse Avenue Sacramento, CA 95825 Re: Melva Jeanne Barkley, KPN 0057339 Dear Ms. Ramirez, I have a problem that has been slowly bubbling its way to the surface of my mind since June 21, to the point that now, 3:30 in the morning, I need to ask the questions. Do you folks run statistical correlations between nursing staff on duty and code blue events? On the evening of June 21 I was by my wife's bedside in G8 in Camellia, reading. It was an MRSA room so we were alone. I had the door ajar about a foot to cut down on the noise. Jeanne's breathing seemed labored but not that unusually so since she was an asthmatic. At about 7:30 a nurse came in, and either checked her vitals, or gave her an insulin shot, or both, and then left, closing the door behind her, which struck me as odd at the time. I got up and opened the door, again leaving it about a foot ajar. When I returned to Jeanne's bedside she was still asleep, but this time her eyes were open and unblinking. From subsequent events I now know that was a bad sign. 15 minutes later her breathing slowed, and began periods of what I've heard called apnea, gaps in breathing. I became alarmed and went up towards the nurses' station and saw in the break room the nurse I think was the one who'd just been in there and asked her "Shouldn't she be on a monitor? She's forgetting to breathe" (they'd been treating her for a pulmonary embolism, among other things), and was assured that Jeanne was OK because she'd just checked on her. I returned to G8 and watched Jeanne breathe her last breath and start to turn gray in front of me. Frantic, I again went to the nurse's station and this time said "she's forgetting to breathe, she's stopped breathing." This second nurse came back to the room with me, checked Jeanne and called the code blue. A few minutes of frantic activity produced a heart beat and I was relieved that Jeanne would be OK. Unfortunately they said her brain was without oxygen for 15 minutes, although later I realized it may have been a half hour since her eyes rolled open. After 3 days of escalating activity it was obvious they would not be able to keep supporting her blood pressure and I had them remove her from life support on June 24. I paid the coroner to do a full autopsy, they released her body on July 1, and Jeanne was buried yesterday. My question is this: do you have an "angel of mercy" on your nursing staff? Michael J. Barkley