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| Lack of Communication Proves Deadly for Inmate |
| By networkworld.com |
| Published: 03/31/2010 |
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A sad story caught my eye in a local paper recently. A 23-year-old anorexic prisoner died in prison in Swanton, Vt., in August 2009 because of a chain of human errors. The tragedy has valuable – if tragic – lessons for all of us involved in mission-critical operations, from controlling production systems through responding to computer intrusions. The editorial "System failed" in the Barre-Montpelier Times Argus newspaper of March 10, 2010 summarizes the story of Ashley Ellis as follows (quoting directly but with added numbering and some [clarifying labels]): 1. Ellis's doctors faxed her records to a doctor in the Corrections Department's health services. This was two days before Ellis was to report to prison. 2. The Corrections doctor faxed Ellis's records to a nurse [Nurse 1] at the prison. 3. The next day the nurse [Nurse 1] e-mailed a regional director of the Prison Health Service [the private firm with a contract for healthcare in Vermont prisons at that time] in California. By the end of the day the regional director authorized the nurse [Nurse 1] to order Ellis's medication. But the nurse [Nurse 1] did not do so because it was the end of the day. 4. The next day – the day Ellis was to arrive – the nurse [Nurse 1] handling Ellis's case had to fill in for another nurse [Nurse 2], and so another day went by without anyone ordering Ellis's medication. 5. The next day a different nurse [Nurse 3] found Ellis's chart on her desk, and she ordered the medication. But she found that the prison did not have it in stock, so she ordered it from a pharmacy in St Albans. She left a message with a nurse [Nurse 4] on the night shift to pick it up on her way to work [that evening]. 6. The night shift nurse [Nurse 4] didn't listen to her messages until the next day, and so she arrived at work in the evening without the medication, and the pharmacy was soon closed. 7. The next morning Ellis died. Read More. |
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