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Errors and neglect lead to deaths at Chicago safety net hospital

by John R. Fischer, Senior Reporter | October 19, 2022
Risk Management
Neglect and errors have allegedly been the cause of at least 13 deaths at Roseland Community Hospital in Illinois since January 2020. (Photo courtesy of Roseland Community Hospital)
Errors and neglect at Roseland Community Hospital in Chicago’s South Side have been responsible for the deaths of at least 13 patients since January 2020.

Four of the deaths have resulted in lawsuits and two were reported by a former Roseland physician in a whistleblower complaint. All 13, which included one pregnant woman, occurred in several departments under the watch of different employees and leaders, reported ProPublica and WTTW News in a joint investigation.

Some of the deaths reported include:
  • One from respiratory failure from allegedly delaying insertion of breathing tube
  • Three linked to failure to check vital signs
  • One due to a seven-hour delay in insulin treatment
  • Two linked to monitoring and assessment lapses

Additionally, the safety net hospital has been cited at least 72 times by federal regulators since January 2017, more than any other hospital in Illinois. It has received eight immediate jeopardy citations for problems left uncorrected, that pose harm or death to patients.

Roseland says it has addressed these deficiencies since 2021, with all warnings having been lifted, and is enhancing safety protocols. Lisa McGiffert, former director of the Safe Patient Safety Action Network, says that does not mean the initial causes have been resolved.

“Not sure there’s anyone looking at these hospitals holistically,” she told ProPublica. “[Regulators] will say, ‘We found infection control breaches in a particular room. You have to clean up the sinks.’ But if there’s a more systemic problem, just cleaning up the sink isn’t going to fix the issue.”

Opened in 1924, the hospital today services 12 predominantly Black neighborhoods and six zip codes. An unstable budget over the last decade has pushed it to almost close, led to layoffs, and created an operating deficit in 2022 of over $11 million, according to federal tax documents.

Understaffing is also a problem, with Roseland cited three times since 2017 for failure to have an adequate number of ER and ICU nurses, and the pandemic only making the issue worse.

The hospital also violated federal regulations by failing to flag two deaths. Roseland leaders told inspectors that the deaths did not warrant further investigation, and that the circumstances for each were less similar than reports suggest and involved patients with unique conditions.

They also attributed losses to overcrowding and stress among staff created by the pandemic. “Severely ill patients from our community presented in our safety net hospital’s emergency department and sadly some did not survive,” hospital spokesperson Dennis Culloton wrote in an email to ProPublica.

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