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Mass. town, FD sued over ‘multiple clinical failures’ in pediatric cardiac arrest

The investigative report finds Topsfield EMTs “grossly failed to take care of this patient appropriately”


Topsfield Fire Department/Facebook

By Dustin Luca
The Salem News

TOPSFIELD, Mass. — A family is suing the town and leaders in the Fire Department, alleging their handling of a pediatric emergency in 2021, along with an internal policy concerning the use of outside mutual-aid ambulances, were responsible for the death of their 8-month-old infant.

Town officials and their attorneys, as well as fire personnel named in the suit, either didn’t respond or declined to comment on the case, which was filed in Salem Superior Court on July 21. The fire officials include Lt. John Boyle, a paramedic on the call, and town fire Chief Jennifer Collins-Brown, who the lawsuit alleges conspired on an internal policy to decline out-of-town ambulance services when town EMS staff are available.

The suit centers on an early-morning emergency call June 5, 2021. The baby was battling acute bronchopneumonia, struggling to breathe, and being held by his father when he “suddenly stopped breathing.” The parents immediately called 911 and began performing CPR on the baby as they learned to do in a class and guided by a dispatcher over the phone.

The baby was placed on a flat surface — the floor — to ensure the CPR was effective. That CPR stopped when police arrived, as the first officer in the door picked up the baby and left the home to await the ambulance. As the 911 call ended when police arrived, the mother of the baby could be heard in the background saying the officer holding her son “is not doing anything.” The father then asked, “Aren’t you going to give him CPR?” as the call ended.

‘Botched response’

The first officer at the scene entered carrying a bag of medical gear, which included an automated external defibrillator, according to the lawsuit. The bag was dropped at the entrance to the home as the officer approached and picked up the baby, and took him outside while tapping his chest to simulate compressions. The bag of gear was left in the home, where it remained untouched throughout the call, the suit says.

From the moment the baby was picked up by police, he didn’t receive any fresh air via ventilation, and he wasn’t intubated until after he arrived at the Beverly Hospital emergency department at 2:38 a.m. Once he was intubated and his airway was cleared, 13 doses of epinephrine were needed to get the baby’s heartbeat back, which was officially noted at 3:13 a.m., the lawsuit indicates.

After being transferred to Boston Children’s Hospital, the baby was diagnosed with a severe hypoxic ischemic injury to the brain, a condition caused by the brain receiving too little oxygen. “His parents withdrew mechanical support the following day. (The baby) passed away on 6/6/2021,” the suit reads.

What transpired between the time first responders arrived just after 2 a.m. until 2:38 a.m. — during which time Topsfield EMTs were solely responsible for the baby’s care — is the main subject of the lawsuit. It also highlights a years-long practice at the Fire Department to prefer to send town EMS staff to calls instead of more advanced life-support ambulances from private companies.

[READ: DPH/OEMS investigation - Clinical Review, Topsfield FD]

An out-of-town ambulance capable of pediatric advanced life support was dispatched and then canceled by Topsfield the night of the call, though the company continued to drive to a rendezvous point in Wenham, waited for an opportunity to take over, and watched as a police escort and the Topsfield ambulance sped by.

“The case is tragic. This was an 8-month-old boy,” said Adam Satin, an attorney with Boston-based Lubin and Meyer representing the family and baby’s estate. “The evidence is going to be very clear he died needlessly because of the botched response by the people named in the complaint, who were expected to provide competent emergency services, but failed to do so.”

Report: ‘Grossly failed’ in care

The details surrounding the emergency response June 5, 2021, are the subject of a scathing 18-page report from the state’s Office of Emergency Medical Services. The office’s investigation, closed in late 2021, specifically lists six violations of state standards of care. Five cite specific treatment protocols violated by Topsfield firefighters, and a sixth targets the Police Department for “failure to provide effective CPR or AED,” which is noted to be “not within OEMS jurisdiction.”

Three of the four town EMTs reported in their interviews that this call was their “first infant cardiac arrest,” and one of them also indicated the call represented their “first time intubating an infant.” That effort was ultimately unsuccessful, in part because the ambulance was being driven unsafely, according to the OEMS report.

“All four EMTs (involved in the response), from start to finish, grossly failed to take care of this patient appropriately, primarily by failing to provide effective CPR or AED therapy and cardiac monitor rhythm assessment,” the OEMS report reads. “There were multiple clinical failures by all the EMS personnel in this call.”

The report specifically names four Topsfield firefighters, who are all EMTs — Jeffrey Horne, Jason Murley, Lt. John Boyle and Jonathan Hallinan — as principal parties. Boyle and Hallinan are also trained as paramedics. It makes repeated references to Topsfield police Officers Daniel Bell and Joseph DeBernardo, as well, the first who arrived the morning of the emergency. An Ipswich police officer was also briefly on the scene to provide mutual aid if necessary.

DeBernardo was first in the door, entering the home with a bag containing an AED and leaving with only the baby, where he was joined outside by Bell and waited nearly six minutes for the ambulance. During the wait, the report notes, both officers “seem to have not continued effective CPR, nor did they deploy an AED.”

Beginning with the ambulance’s arrival, the report lists several failures by those responding:

  • Horne, an EMT, arrived in the town ambulance and exited with a second bag containing medical gear and an AED, but it was left on the ground and abandoned when the ambulance left
  • Horne and Murley, a second EMT, “put the patient on the stretcher, but did not provide ventilations, nor did they apply an AED”
  • Murley drove the ambulance, waving off a police officer’s offer to drive because the ambulance had “partially defective brakes,” thus taking an EMT away from caring for the patient
  • Murley “drove in a manner that concerned the crew of the patient compartment. ... The driving prevented them from performing a second intubation attempt”
  • Boyle and Hallinan were picked up by the ambulance en route, Hallinan after a fire extinguisher discharged inside a town truck; that incident required a clean-up of the truck and brushing off Hallinan’s clothes before entering the ambulance and joining the situation
  • “Broselow tape,” a tool commonly used in pediatric emergencies to estimate a baby’s weight and determine equipment sizes and medication dosages, was “not used until the hospital requested such near the end of the transport”

The report also indicates that while in the ambulance, the baby was “simply placed and secured directly on the stretcher,” as the ambulance lacked a harness “to accommodate the patient’s small size.” It notes the baby’s mother was in the back of the ambulance the entire time — allowing her to witness the quality of care her child received and recognize inaccuracies in the “patient care report” the town wrote to document the call.

The initial complaint to OEMS alleged that the Topsfield Fire Department “falsified information” in the PCR. The town had reported the baby was getting effective CPR throughout the call.

“With regard to the allegation that the PCR was falsified, the department is unable to make that determination,” the report indicates. “CPR is not only chest compressions, but also ventilation, and but for the brief time during which Hallinan applied the BVM (bag-valve mask), this patient was not ventilated. However, the Department cannot determine whether this reflects a lack of understanding of CPR, or is a knowing statement of false information.”

“The report basically says they almost didn’t know what CPR was,” Satin said. “They weren’t providing CPR of any sort that would provide any benefit to this child, and he lost oxygen as a result, and his brain died.”

The report criticizes the Fire Department for failing “to report this incident to (OEMS) in accordance with the serious incident reporting requirements.” It also emphasized that the town “address the issues around the Topsfield (police) first responders’ actions in this case, in which they broke the ‘chain of survival’ in the CPR process this patient had begun receiving” from his parents.

Suit: Internal policy responsible

The OEMS report effectively ends there, but the lawsuit goes on to address a department policy on mutual-aid requests that led to Topsfield handling the call instead of a better-equipped, out-of-town company.

The suit outlines that the policy was captured in a town Fire Study Committee report in 2015, when then-Capt. Collins-Brown confirmed “the existence of the cancellation policy and custom” to the committee.

“On information and belief,” the suit reads, “Boyle and (Topsfield fire Chief Jennifer) Collins-Brown had actively undertaken efforts to generate political support to create and fund permanent full-time EMS services, to be provided by the Topsfield Fire Department, as both the primary first response and transport ambulance. ... Such efforts had led to this policy or custom to exclude its primary competition, Northeast Regional Ambulance, from calls that might be handled by Topsfield, which resulted in decreased utilization of Northeast’s Regional Ambulance.”

The night of the call, Hallinan’s first act was to “request the dispatch of a mutual aid paramedic ambulance from Northeast Regional,” according to the OEMS report. However, the lawsuit indicates that “Collins-Brown and Boyle, at all relevant times, had formulated this policy, custom and practice regarding the regular cancellation of Northeast Regional Ambulance intercepts.”

During the call, as the town ambulance picked up Boyle, he “immediately directed Murley to cancel the Northeast Regional intercept,” the suit reads.

“This cancellation occurred at 2:23 a.m.,” 15 minutes before the Topsfield ambulance arrived in Beverly, the suit reads. Northeast Regional still drove to a rendezvous point on Route 97 in Wenham, one the Topsfield ambulances drove past with Northeast at the ready. After Topsfield’s ambulance sped by, the company was “never contacted to provide support or assistance for the remainder of the trip.”

“What’s particularly egregious, not only from a legal perspective but more-so for me as a parent of small children ... the ranking officers from the Fire Department called off and canceled the ready, willing, and able assistance of the more qualified pediatric advanced life support certified ambulance that was essentially their competition,” Satin said. The cancellation came “for one reason and one reason only: So they can build up their own experience and skillset of their personnel in real-time emergencies like this.”

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