Kaweah Health whistleblower says he was fired for revealing details of patient’s death to surviving family

A former unit secretary at the Kaweah Health Medical Center emergency department (ED) said he was fired from his job after revealing to surviving family members how a 60-year-old patient died as result of willful inaction by the medical staff.

A state investigation of the fatal October 2023 incident found multiple violations by Kaweah Health. And the resulting report – presented here in its entirety – confirms the former employee’s version of the tragic events.

In a statement, state health authorities said: “In regards to this incident, it did not reach the level of an administrative penalty (sometimes referred to as a fine or monetary penalty).”

The deceased patient’s survivors were never informed of the details of their relative’s death.

This lack of transparency pushed former Kaweah Health employee Kevin Barnes to knowingly violate his confidentiality agreement, he said. Initial disclosure was to members of the patient’s family, who had been kept in the dark by the hospital. Last week, with the permission of the family, Barnes took the story to social media.

He said he felt morally and ethically obligated to inform the community when no one else would.

“I knew I needed to say something,” Barnes said. “Someone died.”

ED Nurses Ignored Critical Patient

Barnes, a five-year employee of Kaweah Health, admits he gave details of the man’s untimely – and arguably avoidable – death to his surviving family. He took action to reveal the documented negligence as a whistleblower, he said, after his employer and state authorities failed to inform the man’s survivors of the details surrounding his death in October 2023. After refusing to resign at the suggestion of his employers, Barnes was subsequently dismissed by Kaweah Health for violating patient confidentiality, he said.

A California Department of Public Health (CDPH) investigation of the 60-year-old patient’s death from cardiac arrest in the ED on October 1, 2023 found that two ranking ED nurses – identified in records provided by the decedent’s family as Shelby and Jessica – ignored the man’s obvious distress, as well as the dire radio reports from the paramedics who transported him there by ambulance.

“The facility (Kaweah Health ED) failed to ensure … Patient 1 was triaged upon arrival to the emergency department,” the CDPH’s official findings on the matter, which were released on November 14, 2023, state. “This failure resulted in the delay of a medical screen exam for Patient 1, who suffered a cardiac arrest.”

ED staff were unable to revive the man.

Barnes revealed details of the incident to the man’s family shortly after he learned the full details from reports he was given to file as a regular part of his job as unit secretary. He was fired for that intentional indiscretion in January 2024, and began pursuing legal action for wrongful dismissal that spring. Recently, however, his attempts to find a traditional legal remedy stalled. That prompted him, with the patient’s family’s blessing, to reveal what he had learned to a much wider audience via social media in a March 13 post on Facebook.

Ambulance Crew’s Report Provides Critical Details

A post-incident report filed by an emergency responder from the Exeter District Ambulance (EDA), which transported the stricken 60-year-old man, provides details of the incident from the crew’s perspective. While a redacted version is included with the CDPH’s final investigation report, the entire document – which was eventually provided to the family of the deceased – is more revealing.

It states that while reporting their patient’s critical condition, while enroute to the ED, the crew of the ambulance met unexpected pushback from the mobile intensive care nurse (MICN) at Kaweah Health. The nurse demanded additional information about the patient. The EDA report identifies her as MICN nurse Shelby.

“Call was placed to ED and full report given, with ETA, stat medical, age, sex, chief complaint, patient status, interventions, and MICN nurse Shelby questioned (as) to why (the) patient was stat medical,” the ambulance crew report states.

“Stat medical” indicates the patient requires immediate treatment for a life-threatening medical condition.

When the crew and patient arrived at 5:03 p.m., the ED stat medical response they expected did not happen; it had not been ordered by the MICN nurse. And then the patient’s unstable medical condition suddenly became even more critical.

“As (the) ambulance turned into (the) ambulance bay, (the) patient reported that he felt his defibrillator (had) started to fire and shock him,” the EDA crew report stated. “I reported this information to my EMT partner. Ambulance parked in (a) space and (the) EMT got lift assistance from other ambulance crews. At this time, (the) patient was still verbal and still had seal-like barking during respirations.”

Five minutes after he arrived, the patient’s heart stopped and he went into seizures. Despite vigorous efforts to revive the man, he was declared dead at 5:42 p.m.

Nurses ‘Giggled’ as Patient Struggled for Life

Thirty-eight minutes earlier – revealed by video obtained during the CDPH investigation as being exactly 5:04:17 p.m. – the patient and the crew of emergency responders finally entered the ED. They found MICN Shelby and a second nurse, identified in the EDA report as Jessica, had not prepared for their patient’s arrival.

“As we entered (the) ED through (the) ambulance entrance, nurses Shelby and Jessica were just sitting down, showing no urgency,” the EDA crew report said. “I asked, ‘Which room are we going in?’ They both giggled and delayed patient care, and told me I have to register the patient first.”

The CDPH report states the two nurses remained seated for more than two minutes while the patient lay unassessed and untreated on a nearby gurney.

“The nurses have not left their stools,” the CDPH report said.

The ambulance crew member report describes what unfolded next:

“I told both of them that the patient’s internal defibrillator fired. Shelby responded rudely, ‘Well, you did not say that in your report.’ I told them it just started to happen,” the report states.

The two nurses then required the ambulance crew to register the patient. Meanwhile, the dying man continued to struggle visibly to breathe.

Nurses Demanded Paperwork Before Treatment

The patient went untreated as the registration paperwork was filled out at ED staff insistence.

“It took me approximately three to five minutes to get patient registration completed,” the crew member wrote. “I attempted to hurry the report to both Shelby and Jessica, when Jessica asked, ‘What’s up with that noise your patient is making?’ I reported he’s having difficulty breathing and has been like this the whole time.”

At this point, another ambulance crew pointed out to the nurses that the patient was undergoing a seizure in the nurses’ presence. Yet the two nurses still took no action to treat the patient.

“As this happened, (the) patient started to seize and started having snoring respirations, …” the crew member’s report said. “Shelby and Jessica still did not show any urgency, and the patient went into cardiac arrest on the ambulance gurney in the ED hallway in front of nurses Shelby and Jessica.”

An order was finally issued to move the patient to a treatment room, however the man’s heart had already stopped beating.

“Myself, (the) EMT and (a) firefighter took the patient to Room 25 before the code was even given over the loudspeaker,” the ambulance crew member’s narrative said. “CPR was started, and ED staff took over with patient care. Patient report was given to (the) attending staff MD. Patient was pronounced dead at 17:42 (5:42 p.m.).”

State Investigation Began the Next Day

Barnes said he and a member of the ambulance crew that transported the doomed patient both filed complaints with the CDPH within hours of the incident. The CDPH responded immediately, starting its investigation the next day, October 2, 2023.

That investigation included an interview with a doctor who happened to pass by as the patient was being unloaded from the ambulance at the Kaweah Health ED. The unidentified MD agreed with the assessment of the ambulance crew. The patient’s condition “was a ‘stat medical,’” and the patient “should have gone straight to a (treatment) room.”

Late on the afternoon of October 2, the CDPH investigators spoke to MICN nurse Shelby to determine why she had not assigned a triage level to the patient before his arrival. She told them she had been unable because she did not have the patient’s vital signs prior to his arrival. However, the patient’s vital signs had been transmitted to her by the ambulance crew.

The MICN nurse declined to explain to investigators why the patient was not taken upon arrival for treatment, and was instead left in the ED hallway.

“When MICN 1 was asked why the patient was not taken to a room immediately, and instead (MICN 1) told the paramedic … to register Patient 1, she stated, ‘I have nothing to say why the patient didn’t go to a room sooner,’” the CDPH investigation report states.

The CDPH found two violations of state statutes. First, a violation of Nursing Service Policies and Procedures that implies Kaweah Health failed to maintain the requirement that “written policies and procedures for patient care shall be developed, maintained and implemented by the nursing service.”

Kaweah Health also failed to meet the requirements of the statute covering planning and implementing of patient care, the state found. The failure to treat the patient upon arrival “resulted in the worsening of (his) health condition,” the CDPH investigation report stated.

The family of the dead patient is seeking legal action against the Kaweah Delta Health Care District, which owns and operates Kaweah Health Medical Center and its ED.

Whistleblower Acted to Protect Community from Kaweah Health

Barnes, whose job as unit secretary for the ED included filing official reports, was not at work when the incident took place. He arrived for a 12-hour shift less than one hour after the patient died. The entire ED, he said, was buzzing with the news.

“That’s the first thing we heard was Shelby and Jessica let a patient die in the hallway. That’s the exact words I was told,” Barnes said. “They (coworkers) said a sick patient came in and they (ED nurses) didn’t do anything, and they were in the hallway and didn’t do anything at all until he went into cardiac arrest.”

Barnes said he believed the stories were exaggerated rumors.

“I worked this (job) for five years. I know these nurses,” he said. “They’re good nurses. They’re not well liked by their fellow nurses.”

He expected to receive official documentation of the incident as part of his shift work, hoping to find details that would reveal a less sinister-seeming truth. Less than an hour before his shift ended on the morning of October 2, 2023, he received the report from the EDA crew member. He was shocked by the unusual level of detail he discovered in the report and the accusations it contained.

“I was looking for the information that was going to debunk the rumors we were hearing at work. I still can’t believe it,” he said. “I must have read it over and over and over again, because I mean it was actually worse than what we had heard. It was way worse than I had heard. They said they (the ED nurses) were on their phones while the patient was struggling in front of them.”

Barnes said he believed Kaweah Health would never reveal how incompetent behavior on the part of ED nurses contributed to worsening the patient’s condition. He said administrators at the hospital are concerned with protecting the institution’s reputation before protecting the public health. Barnes feels the administration’s behavior during this incident and others he’s witnessed that resulted in little or no negative consequences for the hospital and staff are part of an overall pattern of institutionalized abusive behavior.

“To work at Kaweah is to know how they operate,” Barnes said. “It’s dysfunctional. There’s no other way to describe it.”

Whistleblower Knew Family of Deceased Patient

While Barnes learned the name of the deceased patient while recording documentation of the incident, it wasn’t until later he connected that name to friendships from his distant past. He knew the man’s four children. He had grown up with them and attended the same schools.

“I was talking to one of my coworkers and she said let’s look up this patient on Facebook, let’s see what he was like,” Barnes said. “The first thing that popped up was this guy’s obituary. Someone I know had posted it.”

Despite the personal connection to the family of the deceased, Barnes still felt obligated to maintain his oath of patient confidentiality. However, the news that he knew the family spread among his coworkers. He said he was approached by five different ED nurses who urged him to tell the family what he’d learned.

“The last nurse said, ‘I heard you know the family.’ She said, ‘Do what you want with this information, but the family doesn’t know the truth,’” Barnes said. “I felt like people wanted me to tell them. I prayed a lot, and it took me a couple of weeks to figure out what to do. I could have just forgotten about it and moved on. I just felt like it was the right thing to do. I know if it was my dad, I’d want to know the truth. So, I reached out to the family.”

He met with one of the man’s sons in person to avoid creating a paper trail.

“I didn’t even know where to start. We just sat there in awkward silence. Then I asked him, ‘What do you know about your dad’s death?’” Barnes said. “And he said he had a heart attack and died on the way to the hospital. My jaw was on the floor, because I know that’s not what happened.”

Barnes then told the man how his father had been alive and communicating when he entered the ED. How the nurses had made the ambulance crews fill out paperwork while the man’s condition rapidly deteriorated. How they didn’t act until the man’s father’s heart had stopped.

“He was very emotional,” Barnes said. “I’d never really seen that side of him. He said he had a feeling and something didn’t make sense to him. He just felt something wasn’t right, but they believed what the hospital told him.”

The man asked Barnes for advice. Barnes told him to get his deceased father’s medical records and hire an attorney.

Whistleblower Had ‘Gut Feeling’ His Fate was Sealed

Long before the ax finally fell, Barnes believed doing what he felt was the right and moral thing to do – telling the surviving children how their father died – would be the end of his career with Kaweah Health.

“I knew that if I talked to them I was going to lose my job. It was just a gut feeling I had,” he said. “I didn’t expect to lose the job the way I did. I thought they’d watch me and fire me for the dumbest thing they could find.”

Instead, they were methodical and slower to act. Barnes last day at work came in December 2023, just two and a half months after the patient had died. He was informed he was under investigation and to report to human resources immediately.

“I go in, and there’s a table full of people,” he said. Among them were the hospital’s risk management executive, the ED director and supervisor, and HR personnel.

“They said they were bringing me in because it was discovered I had discussed a deceased patient’s information with the family. They said the name of the patient and asked me if it was true,” Barnes said. “I sat there for a few minutes. What do I do? I knew the family was getting a lawyer. I knew this was more than work. I didn’t want to do anything wrong. I’m not a good liar. I didn’t want to look stupid, because the truth always comes out.”

He admitted what he had done. More intense questioning ensued.

“They wanted to know everything. I gave them really vague answers,” Barnes said. “When they asked me who I talked to about this (among hospital personnel), I said I talked to everybody.”

The administrators said Barnes’ actions were in violation of the Health Insurance Portability and Accountability Act (HIPAA) that protects patient privacy. He still does not believe his actions went against the intent of that law.

“I said I felt I had a moral and ethical responsibility to do this. They said I didn’t,” Barnes said. “I just kept saying I didn’t do anything wrong.”

Whistleblower’s Choice: Resign or Be Terminated

Despite Barnes’ admission that he’d informed the family of Kaweah Health’s lying when their loved one died, he was told he was “suspected” of a HIPAA violation and was placed on paid administrative leave. He was told he would be informed when the investigation was complete and told the status of his employment at that time.

After a week of paid leave, they offered him a seemingly easy way out.

“They told me they were going to give me the option to resign, and if I didn’t they’d have to terminate me,” Barnes said. “They said I’d put the hospital at risk.”

Barnes said rumors in the ED were that the administration offered the same deal to the two nurses involved in the patient’s death. They chose to resign, Barnes claimed, and are still working as registered nurses at other facilities. He declined to quit his job.

“I said no,” Barnes said. “If you guys want to fire me, you can fire me. They terminated me.”

His last day of employment with Kaweah Health was January 8, 2024.

Whistleblower Says Kaweah Health Holds Many More Secrets

When he finally went public with his disclosure of the events of the patient’s untimely death this month, Barnes felt as if a weight had been lifted off him.

“I feel great,” he said. “I feel like the community knows what happened.”

This incident, he said, was a clearly and fully documented case of failure to treat a patient as required by state statutes. And Barnes said he’s aware of other similar failures that led to patient deaths and other bad outcomes.

“I don’t believe this was an isolated incident,” he said “It would be different if there were a true mistake here.”

His social media post has inspired many similar stories about experiences at Kaweah Health Medical Center.

“It seems like a lot of people have had a lot of issues with Kaweah,” he said. “The comments are flooded with their stories. People have messaged me with long descriptions of their stories. It’s sad. It’s really sad.”

Kaweah Health did not respond to repeated requests for comments about the patient’s death and Barnes’ termination of employment.

Barnes said he believes Kaweah Health attempted to quash the facts behind the death in the ED on October 1, 2023. And he believes such behavior is typical of the hospital’s administrators.

“I think it’s bad management at Kaweah for too long,” he said. “It’s promoting your favorite nurse instead of someone more qualified. And it’s just greed. I think Kaweah lied about this because they don’t want to get sued by the family. I feel like there was a big cover-up by Kaweah. I saw the medical records because the family let me. There’s no mention of what happened in any of the notes. The only thing that tells the truth is the ambulance report.”

Barnes said he acted to protect other families who are likely unaware their loved ones might have received less than adequate care at Kaweah Health.

“A big part of why I wanted to post on social media was I felt this wasn’t an isolated incident,” he said. “The family told me they felt something wasn’t right. I want families to get the medical reports. I want to create awareness. I know for a fact there are other patients (who did not receive proper care).”