A 22-year-old Ohio mom traveled from her home in Columbus, Ohio in October 2017 to check into a drug detoxification center outside suburban Phoenix. She was dead within 72 hours.
Attorneys representing Madison Cross’s parents, Bobbie Ziemer and Kevin Cross, and her daughter, Kinsley Cross, say in a lawsuit that Serenity Care Center failed to order standard tests, diagnose an underlying medical condition and recognize her worsening symptoms, factors that could have prevented her death.
The lawsuit, filed Oct. 1 in Maricopa County Superior Court in Phoenix, names as defendants Serenity Care Center, Aid in Recovery, Pinnacle Peak Recovery and Treatment Management Company, and two medical providers, Dr. Reyes Topete and physician assistant Paul Bratcher.
A spokesman for Serenity and its affiliates declined to discuss the lawsuit. Bratcher did not return a message left at a clinic where he works. The defendants have not yet responded to the lawsuit in court.
Topete, who supervised Bratcher, said the Arizona Medical Board investigated the case and "found nothing wrong on my part." However, the board said in a Feb. 12 advisory letter Topete had "inadequate oversight" of providers and an "inadequate delegation agreement with a physician assistant."
He was not disciplined nor was he fined; the board warned "continuation of the activities that led to the investigation" could prompt action. The state's physician assistants board dismissed a complaint against Bratcher.
In 2017, Americans entered inpatient, outpatient and residential treatment programs more than 2 million times, according to the Substance Abuse and Mental Health Services Administration. The agency reported 3,788 deaths.
Cross's family said she agreed to seek treatment at Serenity because she wanted to recover from substance-use disorder to care for her then-2-year-old daughter Kinsley.
Serenity or its affiliate companies arranged a flight from Columbus to Phoenix on Oct. 7, 2017, then ground transportation to the detox center located in nearby Sun City, according to the lawsuit.
Cross did not know she had pneumonia when she checked into the detox center, and Serenity did not properly screen or test her when she arrived at the center, the complaint contends.
Serenity’s standard admission orders require a doctor, physician’s assistant or a registered nurse take a patient’s medical history, perform a physical exam and take blood tests, according to the lawsuit. But the family asserts Cross was never screened by a doctor or a registered nurse, and the staff did not complete the blood tests, a complete blood count or a comprehensive metabolic panel, which might have detected her illness.
John Wrona, an attorney representing the family, said the lack of testing represented a “very poor beginning, and it didn’t get better.”
Even though staff did not complete the blood tests, there were other signs her condition was worsening, the lawsuit states: Cross was jaundiced; her face and lips were discolored; her pulse raced to 167; her pulse oxygenation rate dipped to 87%, below a normal range in the high 90s.
Instead of sending her to the hospital on the morning she died, Serenity’s staff gave her a beta blocker, propranolol, lowering her pulse rate without treating her underlying condition, “in effect stopping the one thing that was keeping her alive,” the lawsuit states.
She collapsed in her room and was left on the ground for at least six minutes before staff entered. Unresponsive, she was transported to a hospital less than one mile away where she was pronounced dead.
The Maricopa County Medical Examiner’s autopsy determined her cause of death to be septic complications of acute bronchopneumonia, according to the lawsuit.
The lawsuit contends the toxicology report findings “lead to one conclusion: that any opioids in (Cross’s) system had been consumed prior to her admission,” to the detox center on Oct. 7.
The lawsuit said a Serenity spokesman falsely claimed in a media report Cross had consumed illicit drugs after she was admitted to Serenity.
If Serenity's staff had ordered blood tests and recognized her high pulse rate, "abnormally low" oxygen rate and low fever despite receiving Tylenol, her "pneumonia would have been timely diagnosed and treated, and her death prevented," the lawsuit states.
Wrona said Cross’s pleas to be taken to the hospital were ignored or discounted.
“She was so ill, she was trying to advocate for herself. But you have to understand what she was up against,” Wrona said. “There was a culture there not to transfer people out because they were billing gigantic amounts per day, and they won’t collect that money if the person goes to the hospital.”
Wrona added that Serenity's staff, per its policy, took her phone when she was admitted so she could not call family and report her worsening condition.
“It is not like she could call her mom and say, ‘Mom, I’m sicker than I’ve ever been and these people won’t send me to a hospital. Can you help me,’” Wrona said. “She was 100% dependent on the judgment and acumen of the collective Serenity team to protect her from the underlying medical condition. They utterly failed.”
Inpatient drug rehabilitation and detoxification centers have faced scrutiny from Congressional investigators for both marketing practices and quality of care.
The influential House Committee on Energy and Commerce held two hearings in 2018 on the business practices and sales and marketing techniques of treatment centers targeting people battling drug and alcohol addiction, including an estimated 2.1 million Americans with opioid-use disorder.
Wrona said it's difficult for consumers to assess the quality of inpatient detox and rehab centers because there is an absence of publicly-available information. Furthermore, families seeking treatment often have a small window of opportunity to send a loved one to a treatment program and lack the time to research a center's quality.
"People who are choosing these places are in desperate need to help themselves or help family members who have this disorder," Wrona said. "I don't think there's much time for people to vet these places."
This article originally appeared on USA TODAY: Sun City West, Arizona detox center sued after 2017 death of Ohio mom