Investigating a Tragedy

Months after the death of seventeen-year-old Jèsica Santill·n, Duke Hospital is continuing its investigation of a heart-lung transplant error that has prompted intensive media scrutiny and public discussion of related medical, legal, and public-policy issues.

Santill·n underwent a second heart-lung transplant February 20 after her body rejected the first set of organs, transplanted February 7, because they were not the correct blood type. The second set of heart and lungs was successfully transplanted, but on February 21, doctors treating her detected significant worsening of brain function. Despite aggressive medical support, her condition worsened, and she died the next day.

" All of us at Duke University Hospital are deeply saddened by Jèsica's passing," said William J. Fulkerson, chief executive officer of the hospital. "Jèsica's care team is especially saddened. We want Jèsica's family and supporters to know that we share their loss and their grief. We very much regret the heartbreaking circumstances surrounding her care.

" The original mismatch was a tragic error, and Duke accepts responsibility for our mistake. Every effort was made to save Jèsica's life. I give my heartfelt sympathy to her family and supporters, and I thank the entire care team who worked so hard to sustain her."

The case has sparked broad public discussions. Bioethicists have used it as an opportunity to consider the ethics of organ transplants and re-examine who should be given priority when scarce organs become available. Leaders of organ-procurement groups hoped the case would encourage more people to register as organ donors. Public-policy experts discussed how the case might affect tort reform legislation pending in Congress.

In the Triangle, concerns about how Duke handled the case were heard alongside a strong outpouring of support for the hospital and physician James Jaggers, the respected transplant surgeon who took responsibility for the mistake. In both Durham's Herald-Sun and Raleigh's News & Observer, several letters to the editor from community members expressed sadness for Santill·n's family as well as concern for Jaggers.

" We should also offer our sympathy (and admiration) for Dr. James Jaggers, who has taken full responsibility (almost unheard of today) for the mistakes made while Jèsica was in the care of Duke University Medical Center," one correspondent wrote in the News & Observer. "Despite the 'reverence' many of us give to our physicians, they still are only ordinary human beings. By all accounts, Jaggers is a compassionate and skillful surgeon who for years has given of his skills by performing free heart surgery in Nicaragua."

Caregivers at the hospital's Pediatric Intensive Care unit offered similar sentiments in a statement they released. "It has been our great blessing to work alongside [Jaggers] and to witness, firsthand, his unique combination of skill, compassion, and honesty with patients and staff alike," they said. "He is a great teacher and an inspiration to all of us with whom he works. As parents, we would all undoubtedly choose Dr. Jaggers if our children needed the skilled hand of a surgeon."

Meanwhile, the hospital launched a review of the organ-procurement process and established additional internal safeguards. Officials there are cooperating with reviews by the Joint Commission on the Accreditation of Healthcare Organizations, the North Carolina Division of Facility Services, the North Carolina Medical Board, and the United Network for Organ Sharing, which coordinates the national organ-donor list.

Duke is reviewing all aspects of its organ-procurement procedures and has already made changes to ensure that the events that occurred in Santill·n's case will not be repeated. In a statement, Ralph Snyderman, chancellor for health affairs and president and chief executive officer of the Duke University Health System, said, "We are committed to learning from this event, improving the system, and sharing that information with others. And, we are committed to earning the continued trust of our patients. Jèsica's memory compels us all to accept nothing less."