She believed her mom died peacefully. Two years later, a nurse wrote to say what really happened

Family had been kept in the dark about mother's final moments at Kindred Hospital Sugar Land

Manuela Chapa, on her 85th birthday in 2012.

The package came in January: An anonymous letter and a stack of government records, stuffed in a yellow envelope with no return address and mailed to her late mother's home in Damon.

Cris Chapa ripped it open and began to cry.

She thought of the day, March 12, 2015, when medical staff at Kindred Hospital Sugar Land sat her down in a waiting room. They'd said there was nothing anyone could have done. Led her to believe her 87-year-old mother's death had been the inevitable result of her bout with pneumonia.

The stranger's letter told a different story:

Her mother hadn't died peacefully, it said. Instead, a doctor had attempted a procedure without Chapa's knowledge or legal consent, and it had gone badly. Blood poured from a tube in her mother's neck. Soaked her hospital gown. Caused her heart to stop.

Why hadn't anyone told her what happened? Why didn't anyone tell her three months later, when the state sent someone to investigate? Why didn't anyone tell her a few weeks after that, when the federal government cited the hospital for violating her mother's rights?

For nearly two years, Chapa and her family had been kept in the dark. Until now.

She didn't know it then, but the stranger who'd written the letter had mailed duplicates to two of her siblings. Chapa's hands shook as she studied the documents, looking for clues to who'd sent them, but found only an email address.

That night, she logged onto her computer and typed a message: "Can you call me?"

***

Linda Patton read the email twice, unsure how to respond. She'd been hesitant to contact Chapa in the first place, even anonymously. She'd already lost so much.

This wasn't the life she'd hoped for when she accepted a job as a nurse practitioner at Kindred Hospital Sugar Land in September 2014. She knew it had been a risk leaving Houston Methodist Hospital for a less-prestigious facility, but Kindred had offered her a more senior position and an opportunity to mentor young nurses, which was her passion.

Patton noticed problems right away, she said. On daily rounds, she'd quiz nursing staff on what medications patients were taking. What side effects they should be looking for. Basic stuff. Routinely, though, nurses didn't know the answers, and some seemed agitated by her attempts to educate them.

"That just kind of shocked me," Patton said.

She hadn't realized her new hospital had a history of mistakes. In the three years leading up to her first day at Kindred, the federal Centers for Medicare and Medicaid Services had cited the facility for 10 separate violations of state rules governing patient care.

Among the citations, obtained by the Houston Chronicle through a public records request: Kindred nurses weren't adequately trained or supervised. Patients had been unnecessarily restrained. Others had suffered infections after staff mishandled contaminated materials or failed to properly wash hands. Administrative safeguards weren't in place to prevent future mistakes.

In 2012, according to one citation, a patient in Kindred's intensive care unit became disconnected from a breathing machine and was left to die, even as an alarm sounded, alerting staff of the problem. One staffer who heard the beeping said she didn't know what it meant.

J. David Cross, the chief executive officer of Kindred's Houston-area district, defended the hospital's quality of care, noting that the facility exceeds national benchmarks for complication rates.

"We take seriously any issues brought to our attention by regulatory authorities, and work with them to address any concerns," Cross wrote in an email to the Chronicle. "We share the same goal — to provide quality care to our patients."

Patton was troubled by the problems she saw but felt she'd begun to make progress. Some nurses had become receptive to her on-the-job training, she said, and hospital leadership initially seemed to appreciate her efforts to instill a more professional culture.

She'd been there seven months when Cris Chapa brought her mother, Manuela, to the hospital with pneumonia.

Patton checked on her daily and saw her condition grow worse over the course of two weeks. The illness put a strain on her frail heart. Her lungs began to fail. So did her kidneys.

Before leaving for the day on March 12, 2015, Patton checked in on Chapa once more. It seemed clear to her that she might not recover.

Patton assumed doctors would soon be meeting with the woman's family to discuss their options.

***

The next morning, as she arrived at work, a respiratory therapist grabbed Patton by the arm and pulled her aside: "Oh my God, Linda," she said. "It was terrible."

The therapist had been in the room the afternoon before, when Dr. Yassir Sonbol, an interventional cardiologist, tried to insert a catheter in a major vein in Chapa's neck, in the hopes of starting dialysis.

 The treatment might have eased the burden on Chapa's kidneys — but it also came with risks.

On his first attempt at inserting the line, according to medical records and witnesses, Sonbol couldn't get the catheter to stay in the vein. So he tried again on the right side, but this time, the wire got stuck, and Sonbol struggled to get it out.  (Click to Continue)

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She believed her mom died peacefully. Two years later, a nurse wrote to say what really happened