Independent Review of CHA's Response to Death of Laura Levis


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03/28/2019

To the Cambridge Health Alliance Community:

Last fall, the Boston Globe Magazine published a moving account by Peter DeMarco about the death of his wife Laura Levis and her difficulty finding and gaining entry to the Somerville Hospital Emergency Department while suffering a severe asthma attack. Since then, the Board of Trustees, the senior leadership team and the staff at Cambridge Health Alliance (CHA) have made every effort to address the questions and concerns prompted by Mr. DeMarco's story. This included a direct apology to Mr. DeMarco.

As a part of this effort, the Board requested an independent review of the case by former Attorney General Martha Coakley and her colleague Dean Richlin of Foley Hoag LLP. This review was designed to independently assess the facts and identify areas where CHA could improve.

The full report, accessible via the CHA website, is comprehensive and integrates concrete recommendations for improved communications, policies, training and systems. The Board and senior leadership team have had a chance to review the report, and we fully support its recommendations.

Though we believe that it is important for this report to speak for itself, there are a few issues that bear highlighting.

  • The report concludes that the factors leading to Ms. Levis' inability to access the Somerville Hospital Emergency Department and subsequent lack of disclosure about the issues to her family were the result of gaps in systems (policies, training, communication, wayfinding), not failures of individuals. The report concludes that key individuals acted reasonably. However, each and every member of the Board and senior leadership team has made it clear that we are ultimately accountable for these systems failures and that changes will be made to correct them.
  • Medical peer review is a standard practice in health care that allows for confidential and transparent sharing of experiences and perspectives to assess safety events and improve quality. This review included the analysis of peer-review protected information. Out of respect for the peer-review protected details in the report, peer-review material has been redacted from the publicly available version. The Board has reviewed both the complete report and the publicly available report. We are confident that the redacted version provides full access to the issues of interest to both CHA and the broader community.
  • The timeline of what happened before, during and after Ms. Levis' death is no less difficult to read today than it was in Mr. DeMarco's article, but it is very important as a way to understand the systemic failures at play and implement the recommendations for addressing those issues.

This report would not be as thorough or productive if it were not for the full and transparent cooperation of the entire organization, and we appreciate their participation in and support for this process. Additionally, we owe an enormous debt of gratitude to Mr. DeMarco for bringing the issues that contributed to Ms. Levis' death to light. We also appreciate his participation in the review process.

Where do we go from here? The special committee of the Board charged with overseeing this review will continue its work during the next two months. Working with other Board members and senior leadership, its focus will be on developing a path for the organization to move forward with the recommendations in the report.

In addition, we hope to collaborate with Mr. DeMarco and other members of Ms. Levis’ family to develop an appropriate and enduring way to honor her life and legacy. This begins today with publicly sharing Foley Hoag’s findings and the recommendations, but we know that more can and should be done.

This has been a challenging process. However, CHA is stronger and more transparent as a result of it. We thank our staff, our patients and the communities we serve for their continued support.

On behalf of the CHA Board of Trustees,

Josh Posner
Chair, Board of Trustees
Cambridge Health Alliance