Next Tuesday a West Virginia family will mourn the death of their loved one on the two-year anniversary of a tragic farming accident and the day University of Virginia Medical Center mistakenly sent them home with his amputated body parts. It’s tragic enough losing someone but imagine hours after finding out about his passing, you were given his arm and fingers.
Bradley Beckwith was flown in critical condition to UVA on November 26, 2011 after the 27-year-old lifelong farmer got wrapped by his sweatshirt string around a power takeoff shaft on his family’s farm in West Virginia. The accident amputated his right arm and the fingers from his left hand.
The father of two died in the operating room at UVA before his family could make it there by car. When Beckwith's wife Chandra and in-laws Rocky and Betty Sharp arrived at the hospital they were greeted by a chaplain and given the opportunity to say one final goodbye.
"They got ready to leave and the nurse said 'you can take Bradley’s belongings with you' so he just picked the bag up that they handed him and left." Bradley’s father Ronnie Beckwith said.
Rocky Sharp left the hospital carrying the bag. He noticed it was unusually heavy and wet but figured it was just from Bradley’s steel-toed boots. He placed it in the car and a family member had to sit on it to make room for all the passengers.
"When he got to the house he took the bag out and put it in the building. Chandra said 'you might want to go out and get Bradley’s wallet because the bag felt wet,'” Ronnie Beckwith said. "When he went out to get the wallet, he reached in and grabbed a hold of Bradley’s arm…that's about where he lost it."
Sharp decided to keep the shocking discovery of his son-in-law's amputated arm and fingers from the rest of the family while they laid Bradley to rest on the farm where he was raised. He contacted UVA about the situation.
Virginia Department of Health documents show that at 12:40 a.m. November 27, 2011 Sharp first notified UVA about its error. The report shows he was told "Well, you signed for it.” He explained that was incorrect and the operator went on to say it wasn't his department.
At 7:30 a.m., more than six and half hours and several phone calls later, Mr. Sharp was contacted by the first senior hospital administrator after demanding answers on what to do with his son-in-law's body parts. He was told, "I guess you need to take it to the funeral home." It was at Randolph Funeral Home where Bradley’s father-in-law was able to relinquish the bag with his remains.
It would be two months before Chandra, and the rest of the family would find out about the mix up. The Beckwiths say the Sharps and Chandra Beckwith settled with the hospital after months of trying to seek justice for a beloved father, husband and a son-in-law who is now buried under his favorite tree on the farm where his life started and ended.
We reached out to Chandra Beckwith and her parents through their lawyer but they declined to be a part of this story. Bradley's father confirmed they are unable to talk because of the settlement. The Beckwiths do not hold it against them for suing, Bradley’s father said this has been extremely hard on them. They truly loved his son as one of their own. He feels they were given the run around by the medical center.
Ralph Beckwith says UVA Medical Center is the best and they have no regrets sending Bradley there. They say UVA saved Bradley’s uncle's life two years ago after his arm was amputated so it was the natural choice for Bradley. They say the nurse who handed over the wrong bag did not do it maliciously; it was simply a terrible accident.
"It’s pretty devastating. It was already bad enough that I lost him,” Ronnie Beckwith stated. “I still think the hospital is a very good hospital. I think that they need to rethink their higher up in the hospital."
The University of Virginia declined our request for an interview, but put out the following statement: "We have received a media inquiry about a patient event that took place in 2011. The medical center takes responsibility for the mistake made and has apologized to the patient's family for what happened. To ensure an event like this does not happen again, the medical center submitted an action plan that has been reviewed, validated and fully accepted by the Centers for Medicare & Medicaid Services. Due to confidentiality requirements applicable to patient health information, we cannot comment any further."
Bo Cofield, the University of Virginia’s associate vice president for the hospital and clinics operations first said he knew nothing about it when we asked back in March. "I don't know what that tip is, I don't have anything, any specific knowledge of it,” he stated.
But according to the University of Virginia website, Cofield is responsible for the ‘effective and efficient operation of the medical center,’ so we asked again. Then he replied,“OK. Uh. I do know what you're speaking about and we have communicated effectively with the family," he stated.
But according to the report from the Virginia Department of Health, medical center staff did not communicate effectively with the family of Bradley Beckwith. It took more than six and a half hours for medical center staff to direct Beckwith's father-in-law to take Bradley’s arm and fingers to a funeral home.
Erik Bodin, the director of the Virginia Department of Health's office of licensure and certification, said the family had the right to a timely response.
The medical center's mistake did come with consequences. The Virginia Department of Health issued four citations for the negligence. We obtained documents from the state that detail what was found when the health department performed an unannounced, internal investigation of the medical center.
The hospital was found not in compliance with patient rights, quality assurance performance improvement or infection control. The investigation found the hospital staff failed to tell the family about its internal grievance process or right to file a grievance with a state agency.
Investigators found a systematic failure in the operating room. The OR and emergency departments had different plans of action for amputated body parts after a patient's death.
The trauma surgeon told health department officials he noticed a blue laundry bag in the corner of the operating room after Beckwith died. He said he opened it and something flew out, but didn't identify what it was. The investigation showed the bag was next to Bradley’s body, it was a blue bag where belongings are usually stored. The surgeon did not label the bag as a surgical pathology specimen because he did not remove the body parts during surgery.
The next time the bag was handled it ended up in the hands of Bradley Beckwith’s family. When it was finally cut open at Randolph Funeral Home it was three bags deep, with red bags and towels inside.
Bodin said, "That becomes an infection control issue just because you have body leak tissues that are not being properly treated."
After the internal investigation, the medical center was required to submit a plan of correction to the state, so no family goes through the stress that this family did.
"It's emotionally very difficult for the family at a time that's already very emotional, the family is grief-stricken and then to be confronted with this in addition to the loss of this young man, so that makes it all the more tragic I think," Bodin stated.
Amputated body parts must now be placed in a clear plastic bag labeled with patient information and a biohazard sticker.The bag will then be placed in a human body parts cooler. If a patient is pronounced dead in the emergency department, the parts will be placed inside the foot of the body bag and sent to the morgue with the patient. A patient's family must receive a notice of their right to file a complaint. Lastly, hospital staff is required to be trained on the new procedures.
"They have to have processes in place to continually evaluate the quality and type of care they provide," Bodin said.
Just six days after the Beckwith bag mix-up, the investigation also cited the hospital for not properly disposing of another patient’s amputated finger.
The hospital was not fined because of the citations but did lose its "deemed" status, which means the hospital will be on the radar for future state investigations. The Virginia Department of Health has revisited the hospital once since this event to make sure it is in compliance.
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