Morton Plant Hospital
Attn: Risk Management / Quality & Patient Safety
300 Pinellas St, Clearwater, FL 33756
RE: Formal quality‑of‑care concern & request for an independent sentinel‑event investigation
Patient: John Coates MRN: ____________ Dates of Service: 28 May 2025 – 29 May 2025
Why I am writing
I suffered a peri‑procedural myocardial infarction that was provoked at Largo Medical Center and then left unassessed at Morton Plant Hospital when the same two physicians who caused the complication were allowed to direct my care a second time. I am formally requesting Morton Plant to:
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Open a sentinel‑event / root‑cause analysis that is independent of those physicians.
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Release all documentation (records, cath films, incident reports) related to my care and to any internal reviews.
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Arrange an impartial cardiology second opinion and late‑damage assessment (cardiac MRI or comprehensive echocardiogram).
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Amend the record to show that my discharge from Largo was involuntary and that I repeatedly requested—rather than refused—standard‑of‑care testing.
Chronology of key events
| Date & time | Location | What happened | Troponin‑I (ng/L) |
|---|---|---|---|
| 25 May 05:30 | Largo ED (arrival by EMS) | Chest pain; serial troponin rise triggered High‑Risk NSTEMI clock (< 24 h PCI) | 14 → 248 → 2 764 |
| 25 May ≈11:30 | Largo CT / transport | Complete hemodynamic collapse when supine: each time I was laid flat I became totally paralyzed—unable to open my eyes, lift my arms or fingers. Function returned only when staff sat me upright after projectile vomiting. Meets ACC/AHA & ESC “hemodynamic instability / cardiogenic shock” criterion → Very‑High‑Risk (< 2 h) invasive strategy—yet no ICU transfer or emergent cath was initiated. | — |
| 27 May 07:00 | Largo ward | Pre‑PCI troponin (baseline for peri‑MI definition) | 600 |
| 27 May 09:00 | Largo cath lab | PCI by James H. Skorczewski, DO. He stated: “I kinked a small artery—you’re getting ready to have a heart attack.” No rescue manoeuvre performed. | — |
| 27 May 21:00 | Largo ward | First post‑PCI troponin drawn 12 h later—only after I threatened legal action: confirms type 4a MI | 8 638 |
| 28 May 00:30 | Largo | Security seized my phone/computer for audio recording my care; I was forcibly coerced into discharge with no plan for continuing MI management. | — |
| 28 May 01:45 | Home | Dialed 911 to report assault / medical emergency. EMS dispatched. | — |
| 28 May 02:30 | Morton Plant ED | Arrived by ambulance. Admitting & attending: Carol L. Patterson, MD. | — |
| 28 May 03:00 | Morton Plant | Dr Patterson re‑engaged Drs Akash Patel, MD & James H. Skorczewski, DO—the same operators from Largo—as consulting physicians. Dr Patel reiterated: “You’re not going to dictate your care.” | — |
| 28 May 03:30 – 29 May | Morton Plant | Supportive, ECG, telemetry, or echocardiogram ordered; no independent review offered. | — |
| 29 May 14:17 | Morton Plant | Routine discharge. Documentation states “patient left,” though discharge followed my repeated requests for standard testing, which were declined. | — |
Guideline requirements vs. what actually occurred
| Evidence‑based standard (ACC/AHA 2025, ESC 2023, SCAI) | Required actions | Reality |
| Very‑High‑Risk (< 2 h) invasive strategy (hemodynamic instability) | Immediate ICU bed, urgent cath / rescue PCI | No ICU, no emergent cath, sedated on ward |
| Type 4a MI definition (troponin > 5 × baseline plus ischaemic mechanism) | Serial high‑sensitivity troponins at 0‑3‑6 h, continuous telemetry, prompt re‑intervention if rise continues | First post‑PCI troponin at 12 h; no telemetry; no re‑intervention |
| Sentinel‑event policy (unexpected major loss of function) | Independent root‑cause analysis; consultants not involved in event | Same two operators listed as consultants; no independent review |
| Contrast‑induced‑AKI prophylaxis (single kidney) | Isotonic‑saline hydration & renal monitoring | None ordered |
| Patient rights (CMS §482.13) | Freedom from coercion; access to information; ability to record own PHI | Phone confiscated; labelled “self‑discharge” despite involuntary removal |
Clinical consequences
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Troponin jump from 600 → 8 638 ng/L = 14‑fold rise → formal type 4a peri‑procedural MI.
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Registry data show untreated peri‑PCI MI doubles 1‑year mortality compared with guideline‑managed cases.
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Because serial enzymes, imaging, and re‑intervention were omitted, the extent of permanent left‑ventricular damage remains unknown; I now experience marked fatigue and limited exercise tolerance.
Requested actions
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Independent sentinel‑event root‑cause analysis by a team with no prior involvement in my PCI.
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Complete records within 15 days: charts, cath films, lab logs, security/incident reports, and any internal reviews.
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Objective assessment of residual damage—cardiac MRI or advanced echocardiography with strain, repeat biomarkers, and 24‑h rhythm monitoring.
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Correction of the chart to reflect:
• Involuntary discharge from Largo.
• My documented requests—not refusals—for standard post‑MI testing. -
Facilitation of an external peer review or second‑opinion consultation of my choosing.
I appreciate the comfort measures Morton Plant staff provided, but comfort alone cannot substitute for the evidence‑based interventions required for maximal survival and cardiac recovery. Please confirm receipt of this letter and outline your response timetable.
Thank you for your prompt attention.
John Coates
(Enclosures: 1. Troponin trend screenshot; 2. Morton Plant discharge sheet listing consulting physicians; 3. Timeline chart)