Report on Medical Negligence and Patient Rights Violations (May 25–29, 2025)

Formal Complaint

Introduction: John Coates, a 54-year-old patient, suffered a severe cardiac event May 25th 2025 and was treated at two facilities – HCA Florida Largo Hospital and Morton Plant Hospital. This complaint outlines a factual timeline of his care, detailing numerous deviations from the standard of care and violations of the patient’s rights. It is supported by contemporary clinical guidelines (2025 ACC/AHA and 2023 ESC for Acute Coronary Syndromes) and federal patient rights regulations. The incidents described demonstrate medical negligence, procedural guideline violations, and abusive misconduct by hospital staff.

John Coates’s initial hospital course was marked by clear signs of an acute coronary syndrome that were not acted upon in a timely manner. On May 25, 2025, Mr. Coates presented to HCA Florida Largo Hospital’s Emergency Department with symptoms consistent with an ongoing heart attack. He experienced episodic paralysis and projectile vomiting whenever lying flat, extremely high blood pressure, inability to lift his arms, legs, or open his eyes at the peak, and altered mental status. These alarming findings indicated hemodynamic instability and possible neurologic compromise. His cardiac troponin I levels rose precipitously – from 14 ng/L at admission to 248 ng/L, and then to 2764 ng/L within hours – confirming a large NSTEMI (non-ST-elevation myocardial infarction) in progress. Such a steep troponin rise signifies extensive heart muscle injury (infarction). Table 1 below summarizes the troponin measurements over the course of his care:

Table 1: Chronological Troponin I Levels (ng/L) May 25–29, 2025

Despite these objective indicators of a high-risk myocardial infarction, the care team at Largo Hospital failed to perform the urgently indicated intervention. Clinical guidelines classify Mr. Coates’s presentation as High Risk to Very High Risk NSTEMI, warranting early invasive management. As shown in the attached guideline excerpt, patients with very high-risk features (e.g. hemodynamic instability, refractory ischemic pain, life-threatening arrhythmias) should receive urgent cardiac catheterization (PCI) within 2 hours, and those with high-risk NSTEMI (e.g. significantly elevated troponin or dynamic ECG changes) should undergo PCI within 24 hours. Mr. Coates clearly met these Class I criteria – he had unstable vital signs and a troponin rise into the thousands, placing him at extreme risk. No cardiac catheterization was performed on May 25 or May 26, 2025, well beyond the guideline-mandated window for intervention. This two-day delay in definitive treatment represents a gross deviation from the standard of care, during which time the patient’s heart muscle was sustaining avoidable damage.

By the morning of May 27, 2025 – roughly 48 hours after admission – Mr. Coates still had not received an invasive evaluation. Finally, on May 27, a percutaneous coronary intervention (PCI) was scheduled and performed by Dr. James Skorczewski, D.O. (the attending interventional cardiologist). By this time, Mr. Coates’s troponin had drifted down to ~600 ng/L, suggesting the initial infarct had plateaued. The decision to delay PCI for two days conflicted with ACC/AHA and ESC guideline mandates for an “early invasive” strategy in NSTEMI. During the PCI procedure on May 27, Dr. Skorczewski reportedly caused a complication by kinking a side-branch coronary artery. He grimly told Mr. Coates, “You’re going to have a heart attack,” immediately after this mishap. This statement proved prophetic: the obstruction of a side artery set the stage for a new infarction. Yet, after the PCI, no measures were taken to evaluate or mitigate the damage. Standard post-PCI protocol (especially in a complex NSTEMI case) calls for close monitoring and prompt assessment of outcomes – including immediate post-procedure electrocardiogram (ECG) to detect any acute changes, continuous cardiac telemetry monitoring for arrhythmias, and timely checks of cardiac enzymes to gauge any procedure-related MI. Mr. Coates was not placed on telemetry and no immediate ECG or enzyme tests were ordered in the hours following the PCI, leaving his critical status unchecked (a breach of safe care standards). In fact, continuous cardiac monitoring is routinely recommended for ACS patients to watch for recurrent ischemia or arrhythmia hhs.nd.gov, yet this basic safety step was omitted.

Around 12 hours later, in the early morning of May 28, Mr. Coates – who remained in the hospital – personally demanded a troponin test due to ongoing symptoms and concern that something was gravely wrong. The staff initially resisted doing this test. Only under threat of legal action did they finally acquiesce to draw labs. The result, returned at approximately 7:00 AM on May 28, was catastrophic: troponin I 8638 ng/L. This value was over 14 times higher than the pre-PCI level of 600 ng/L (and dozens of times the diagnostic threshold), indicating a massive myocardial infarction had occurred during or after the procedure. In other words, Mr. Coates had sustained a Type 4a MI – an MI provoked by the PCI itself. According to the Universal Definition of MI, a PCI-related infarct is defined by a post-procedural troponin rise >5× the upper reference limit (or a significant >20% rise from an elevated baseline) plus clinical evidence of ischemia. Mr. Coates’s post-PCI enzyme surge far exceeded this threshold, confirming a procedure-induced heart attack.

The critical troponin result (8638 ng/L) on May 28 is visualized in the attached lab report screenshot. This extreme elevation represented new, extensive cardiac injury that demanded immediate clinical response. Guidelines and standard cardiology practice dictate that a post-PCI infarction be promptly evaluated and managed – for example, by obtaining an urgent echocardiogram to assess left ventricular function and wall-motion changes, repeating the coronary angiography to fix any acute issues (such as stent thrombosis or the kinked artery), and intensifying medical therapy. Expert commentary in cardiology literature concurs that post-PCI troponin elevations should prompt action if there is evidence of a complication or ongoing ischemia. In Mr. Coates’s case, there was unmistakable evidence of an ongoing infarction, yet none of the appropriate interventions were undertaken. No echocardiogram or imaging was performed to assess the damage. No repeat catheterization was arranged to address the occluded side branch or any thrombosis. No telemetry or intensive monitoring was instituted despite the risk of arrhythmia from such a large MI. In sum, after causing a procedural complication, the care team failed to follow through with the required diagnostic and therapeutic measures – a lapse that put the patient’s life in continued jeopardy.

Shockingly, the hospital’s response to this medical emergency was not to treat Mr. Coates, but rather to silence and remove him. When Mr. Coates pointed out that he had audio recordings of his interactions (presumably as proof of statements and care deficiencies), the staff reacted with hostility. A nurse, with the aid of hospital security personnel, confiscated Mr. Coates’s mobile phone. They accessed and deleted personal files, including his audio documentation as well as unrelated personal photos and communications. This was done without consent – essentially an unlawful seizure and destruction of the patient’s property. Immediately afterward, while Mr. Coates was still in severe physical distress (actively having a post-PCI heart attack, as evidenced by troponin >8000 ng/L and persistent symptoms), the staff pressed him to sign discharge papers. Under duress and fearing for his safety, Mr. Coates signed the paperwork. He was then escorted off hospital premises on May 28, 2025, in a grossly unstable condition.

These actions by HCA Largo Hospital staff constitute egregious violations of the patient’s rights and standard of care. Federal regulations (42 CFR §482.13) guarantee that “the patient has the right to receive care in a safe setting” and the right to be free from abuse or harassment by hospital staff. By abandoning Mr. Coates in the middle of a medical emergency, the hospital failed to provide a safe care environment. Moreover, the coercive confiscation of his belongings and the intimidation to force a discharge amount to harassment and mental abuse, directly infringing his right to be free from such mistreatment. Patients also have the right to voice grievances about care and to have those grievances addressed promptly and without retribution. Mr. Coates, in effect, raised a quality-of-care concern (requesting a troponin and questioning his management); the appropriate response per regulations was to involve the hospital’s grievance process and ensure his concerns about possibly premature discharge were reviewed. Instead, the staff’s response was retaliatory – to summarily discharge him against his will and without any medical justification, an act completely contrary to CMS patient-rights requirements. The forced discharge of an acutely ill patient is not only unethical and negligent, it skirts dangerously close to the criminal realm of assault and battery (as it involved unwanted touching/seizing of property and intimidation).

After being expelled from Largo Hospital, Mr. Coates’s ordeal continued at Morton Plant Hospital (Clearwater, FL). Around mid-day on May 28, EMS transported Mr. Coates to Morton Plant’s Emergency Department because he was still experiencing chest pain, weakness, and other symptoms of ongoing cardiac ischemia. In the ER, his troponin was measured at 5477 ng/L – still critically high – corroborating that the myocardial infarction was ongoing. In an alarming turn, the same two physicians from Largo (Dr. Skorczewski and a second doctor involved in his case) were effectively assigned to or consulted on Mr. Coates’s care at Morton Plant. This presented an obvious conflict of interest, as those providers had a potential motive to downplay the earlier errors. Consequently, the pattern of substandard care persisted. At Morton Plant, despite Mr. Coates’s recent Type 4a MI and the still-elevated biomarkers, no comprehensive cardiac evaluation was done. He was not sent for an emergent coronary angiography to address the likely occlusion in the side branch. No echocardiogram or cardiac MRI was performed to assess the extent of damage to his heart (e.g., to check for reduced ejection fraction or complications like aneurysm). Mr. Coates was placed on conservative management and observed as an inpatient, with troponin levels checked intermittently. These levels trended down (from 5477 to 3544 ng/L later on May 28, then to 3263 ng/L by the morning of May 29) but remained grossly abnormal. Discharging a patient while troponin is still in the thousands is highly unconventional – such levels indicate significant myocardial injury is still present or only recently peaked. Normally, after a major MI or a complication, standard care is to confirm the patient’s cardiac stability and assess damage before discharge, including imaging of the heart’s function. Here, Mr. Coates was discharged from Morton Plant Hospital on May 29, 2025 without any imaging or intervention, and with minimal understanding of his post-MI cardiac status. The second hospital, therefore, failed to rectify the situation or adhere to guidelines itself. Its staff essentially observed the fallout without proactive treatment, then released the patient still at elevated risk (with unknown left ventricular function and potentially salvageable myocardium untreated). This represents a continuation of the earlier negligence, rather than the expected corrective intervention.

In summary, the care Mr. Coates received from May 25–29, 2025 involved multiple, compounding failures:

• Failure to timely perform a Class I indicated PCI for a high-risk NSTEMI (violating 2025 ACC/AHA and 2023 ESC guideline directives for urgent revascularization).

• Failure to monitor and manage a known complication (post-PCI infarction), breaching standard post-procedure care protocols and causing additional harm.

• Active violation of patient rights and ethical standards by harassing the patient (seizing property, deleting files) and abandoning him while he was still in need of critical care.

• Failure of the second hospital to provide appropriate follow-up care, including lack of diagnostic cardiac imaging and absence of any attempt to revascularize or medically address the injury, further departing from Class I recommendations (e.g., the general principle of assessing LV function after major MI, and complete revascularization when indicated).

These breaches of duty directly resulted in Mr. Coates suffering a larger heart attack than he might have otherwise, enduring needless pain and fear, and having his rights infringed. The actions (and inactions) of the providers and staff involved reflect gross negligence and willful disregard for patient safety and rights. Mr. Coates was entitled to care that met at least the minimum standard – instead he received substandard, dangerous treatment and was mistreated when he advocated for himself. This narrative, supported by the cited guidelines and evidence, forms the basis of a formal complaint of medical negligence, malpractice, and violation of patient rights. Mr. Coates seeks accountability for these failures and assurance that no other patient will be subjected to such an ordeal.

Letter to Morton Plant Hospital Risk Management

Morton Plant Hospital – Risk Management Dept.
300 Pinellas Street
Clearwater, FL 33756

Date: May 31, 2025

From: John Coates (Patient)
Subject: Formal Complaint – Serious Safety Incident and Patient Rights Violations (May 25–29, 2025)

Dear Risk Management Team,

I am writing to formally report a serious case of medical negligence and patient rights abuses that I experienced during my recent care at HCA Florida Largo Hospital and Morton Plant Hospital between May 25 and May 29, 2025. I am requesting your department’s prompt investigation and remedial action regarding these events, which I detail below. This letter also outlines specific resolutions I am seeking, including an independent review, corrections to my records, and proper medical follow-up, to prevent future harm to patients and to address the damage done in my case.

Summary of Events: I suffered an acute heart attack (NSTEMI) on May 25, 2025 and was initially treated at Largo Hospital. My cardiac troponin levels spiked from 14 ng/L to over 2700 ng/L within a day, clearly confirming a major heart attack. I also had alarming symptoms (dangerously high blood pressure, episodes of paralysis and vomiting when lying down, confusion) indicating that I was in an unstable, high-risk condition. Despite these red flags, the cardiology team did not perform an urgent cardiac catheterization. According to current ACC/AHA and ESC clinical guidelines, my presentation met “Class I” criteria for an early invasive intervention (PCI) – ideally within 24 hours or even within 2 hours given signs of hemodynamic instability. Unfortunately, no intervention occurred on May 25 or 26.

It was only on May 27, approximately 48 hours later, that I finally underwent a cardiac catheterization/PCI at Largo Hospital. By that time, my infarct had progressed extensively. During the PCI procedure, Dr. James Skorczewski, D.O. (interventional cardiologist) apparently kinked a side-branch artery while placing a stent. I distinctly heard him say, “You’re going to have a heart attack,” which I interpreted as an acknowledgment of a serious complication. In the hours following the procedure, no one checked on the status of my heart – there was no immediate post-PCI EKG, no monitoring in a telemetry setting, and no prompt blood test to see if the procedure had triggered more heart damage. I continued to feel unwell, with ongoing chest discomfort and weakness.

Early on May 28, I grew extremely concerned about my condition and insisted on a troponin blood test. The staff was reluctant, but I persisted because I knew something was very wrong. The troponin result came back critically high (8638 ng/L) – a level that is about 14 times higher than my pre-PCI value and enormously above normal. This result confirmed that I had indeed sustained a major heart attack during/after the PCI (what is classified as a Type 4a myocardial infarction). In other words, the PCI complication caused an even larger infarction on top of my initial one. This outcome should have prompted immediate action: I should have been taken back to the cath lab for further intervention, or at the very least given urgent therapy and tests (like an echocardiogram to assess the damage). None of that happened.

Instead, what transpired next is deeply troubling. When I pointed out that I had recorded some conversations (in order to have an accurate record of my care), the hospital staff – rather than addressing my medical needs – took punitive action against me. A nurse, with security present, confiscated my phone and deleted my personal text messages and other files. I was then forced to sign discharge papers under duress. I want to be clear: at this point I was in critical condition, actively having a post-PCI heart attack as evidenced by my lab results and symptoms. I pleaded that I was not stable, but I was nonetheless escorted out of Largo Hospital on May 28 while still experiencing chest pain, weakness, and extremely high enzyme levels. I felt I had no choice in the matter – I was essentially expelled for documenting my care.

After being removed from Largo, I had no option but to seek emergency help again because I was truly in peril. I arrived by ambulance to Morton Plant Hospital later on May 28. My troponin upon arrival was still extraordinarily high (approximately 5477 ng/L) and I remained in significant discomfort. I informed the ER and cardiology staff of what had happened prior. I was admitted for observation; however, I was dismayed to learn that the same cardiologist (Dr. Skorczewski) and one of his associates were involved at Morton Plant as well. This raised immediate concern for me about the objectivity of my care. Over the course of that day and the next, my troponin trended down (to ~3544 ng/L and then ~3263 ng/L by May 29). No further interventions or diagnostic imaging were performed at Morton Plant. I did not receive an echocardiogram, cardiac MRI, or any other assessment of the damage to my heart. Essentially, my condition was observed until my enzymes started falling. I was then discharged on May 29, 2025 from Morton Plant Hospital while my troponin was still in the several-thousand range, and without anyone ever visualizing my heart function or addressing the blocked side artery. I was sent home in a fragile state, with instructions to follow up later. This discharge occurred without fully evaluating the injury I sustained or ensuring that I was out of danger.

Violations and Concerns: The events above constitute multiple failures in care and violations of my rights as a patient:

• Deviation from Standard of Care: The lack of timely PCI at Largo Hospital was a violation of well-established care standards for heart attack management. The subsequent failure to address the PCI-induced MI compounded this negligence. Both hospitals missed opportunities to mitigate my heart damage. These actions (and inactions) fell far below the accepted standard of cardiology care and directly conflicted with Class I guidelines for treating NSTEMI and PCI complications.

• Patient Rights Violations: I was treated in a manner that violated fundamental patient rights guaranteed by Medicare Conditions of Participation (42 CFR §482.13). I did not receive care in a safe setting – in fact, I was pushed out of the hospital during a medical emergency. I was subjected to harassment/coercion by staff who took my personal property and erased my files without consent. I was not allowed to voice concerns or seek review of my care; instead, my attempt to advocate for myself was met with retaliation and expulsion. This is completely contrary to the patient rights regulations (which protect the right to be free from abuse, and to have grievances addressed properly). I felt unsafe, powerless, and violated by this behavior.

• Potential Cover-up/Conflict of Interest: The fact that the same physician who caused the complication at Largo was involved in my care at Morton Plant creates the appearance of a conflict. No independent cardiology consult was offered. This situation raises concern that my adverse outcome was not objectively evaluated at the second hospital – effectively, the fox was guarding the henhouse. I worry that this may have influenced the decision not to perform thorough diagnostic tests at Morton Plant, and I fear that my medical records might not fully reflect the true events (for instance, it’s possible my discharge was mischaracterized as “against medical advice” or something else, which it was not – I never wanted to leave). I request verification that my records accurately document that I was discharged involuntarily while unstable.

Requested Actions: In light of these grave concerns, I respectfully request the following from Morton Plant Hospital (and its parent network, if applicable):

1. Independent Root Cause Analysis / Sentinel Event Review: I ask that the hospital initiate a formal Root Cause Analysis of this entire incident as a potential sentinel event. This review should include the care at both Largo Hospital and Morton Plant, since they were sequentially related. The analysis should determine how such a blatant lapse in care (delay in treatment, mishandled complication) occurred and how a patient could be forcibly discharged during an active medical crisis. I urge that this review be conducted by an impartial panel (including quality/safety experts not directly involved in my care) to ensure objectivity. I would like to be informed of the findings and corrective actions taken to prevent this from happening to others.

2. Medical Record Corrections and Preservation: I request a thorough audit of my medical records from both facilities to identify any inaccuracies or omissions. In particular, the records should clearly show the critical troponin levels and the fact that I was discharged while in unstable condition. If any statements in the records contradict what actually happened (for example, if it says I left against medical advice or refused treatment, which is untrue), I ask that those be corrected or that my objection be officially noted in the record. Moreover, all records, including nursing notes, physician orders, consults, telemetry strips (if any), and incident reports, should be preserved and reviewed. Given the deletion of files from my phone, I am concerned about potential loss of evidence; hence, it’s vital that the hospital retain all internal documentation about this incident.

3. Provision of Complete Records: Please provide me with copies of my entire medical file from Morton Plant Hospital and any available records from Largo Hospital (I understand I may need to request Largo’s records separately if necessary, but any assistance in expediting that would be appreciated). This should include all laboratory results (troponins, etc.), imaging, procedure reports (the PCI report and any documentation of the complication), physicians’ notes, nurses’ notes, discharge summaries, and any security or incident reports related to the phone confiscation event. I am entitled to these records under HIPAA, and I request them to better understand what happened and to share with any follow-up healthcare providers or legal counsel. I will provide any written authorization needed to facilitate this release promptly.

4. Adequate Cardiac Damage Assessment and Follow-up Care: I am still dealing with the health consequences of this prolonged and untreated heart attack. It is imperative that I receive proper evaluation of the damage to my heart and appropriate follow-up care. I am requesting that the hospital arrange (at its earliest opportunity) for a comprehensive cardiac evaluation, which should include an imaging study of my heart such as a cardiac MRI or an echocardiogram with strain analysis to assess my left ventricular function and check for any complications (e.g., aneurysm, mural thrombus). I also believe I should be on telemetry or at least have ambulatory rhythm monitoring given the extent of my infarction, to watch for arrhythmias. Additionally, repeating the troponin and other relevant labs in the near term would help ensure that the levels have trended back to normal. If these services cannot be provided directly, then at minimum a referral to a cardiologist for urgent follow-up with these evaluations should be facilitated. I want to ensure I receive the appropriate care now to mitigate any long-term effects of this event.

In closing, I want to emphasize how traumatic this experience has been for me. I placed my trust in these institutions to care for me during a life-threatening emergency, and that trust was severely betrayed. I am determined to ensure that what happened to me is not swept under the rug. I believe Morton Plant Hospital, being a respected institution, will take these concerns seriously and respond in a constructive manner. I ask that you acknowledge receipt of this letter and provide me with a written response outlining how you will address each of the above points.

Thank you for your time and urgent attention to this matter. I hope that by bringing this to light, we can improve the system and prevent any other patient from enduring what I went through. I am available to discuss this further or to provide any additional information you need.

Sincerely,

John Coates (Patient)