Vanderbilt death: Victim would forgive nurse who mixed up meds, son says

The son of a woman who was killed by a medication mix-up at Vanderbilt University Medical Center said his mother would forgive the nurse alleged to be responsible for her death and that her family won't pursue legal action against the hospital where she died.

Charlene Murphey, 75, of Gallatin, died from a medication error at the hospital in December 2017, authorities said. She was publicly identified for the first time on Monday when a former nurse accused of causing her death, Radonda Leanne Vaught, was indicted on charges of reckless homicide and impaired adult abuse.

Murphey's son, Gary, said late Monday that his mother would feel sorrow for Vaught, lamenting that her mistake had now ruined two lives.

“I know my mom well, and she would be very upset knowing that this lady may spend some of her life in prison,” Gary Murphey told The Tennessean. “She probably had a family, and it’s destroyed their life too.”

Before her death at Vanderbilt, Charlene Murphey lived her entire life in the Gallatin area and worked at the local Walmart for 24 years until retiring in 2012 due to failing health. She was a born-again Christian with a friendly smile, a generous spirit and an enthusiastic love of yard sales, family members said.

She was married to her husband, Sam Murphey, 80, for more than 50 years.

“She was a good person – a real sweet girl,” the elder Murphey. “She was a good to me as she could be.”

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Murphey alert, improving before medication error

The medication error that killed Charlene Murphey occurred on Dec. 26, 2017, while Murphey was being treated at Vanderbilt for a subdural hematoma – or bleeding of the brain – that was causing a headache and loss of vision. Despite these symptoms, Murphey was alert, awake and in improving condition, according to the federal investigation report by the Centers of Medicare and Medicaid Services.

The report states that Murphey was taken to Vanderbilt’s radiology department to receive a full body scan, which involves lying inside a large tube-like machine, but she suffered from claustrophobia, so a doctor prescribed her a dose of Versed, which is a standard anti-anxiety medication.

A nurse then went to fill this prescription from one of the hospital’s electronic prescribing cabinets, which allow staff to search for medicines by name through a computer system. The nurse could not find the Versed, so she triggered an “override” feature that unlocks more powerful medications, according to the investigation report. The nurse then typed the first two letters in the drug’s name – “ve” – into the cabinet computer and selected the first medicine suggested by the machine, which was vecuronium, not Versed.

The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. The patient was left alone to be scanned for as long as 30 minutes, according to the investigation report, before someone realized the patient was not breathing. Murphey lost consciousness, suffered cardiac arrest and was ultimately left partially brain dead.

Murphey’s son, Gary, told The Tennessean that family began pressuring Vanderbilt staff to tell them what was going on. Eventually, a doctor told them that it appeared Murphey had been given too much medication or possibly the wrong medication.

“She was so cheery and talking to us and the next thing you know we never got to speak to her again,” Gary Murphey said.

Hours later, at about 1 a.m., Murphey’s family gathered at the hospital to say goodbye. Doctors said she had suffered severe brain damage and would never recover. They recommended taking her off a breathing machine, which was the only thing keeping her alive.

“They said she was not going to get no better,” Sam Murphey said, choking back tears. “So I did it – I had to do it – I couldn’t keep her like that.”

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Family found out about mistake a year later

The next day, a Vanderbilt official confirmed to Murphey’s family that she was given the wrong medication, which caused her to stop breathing during the scan, Gary said. The one thing that Vanderbilt didn’t tell them was what drug Murphey had received by mistake.

The family found that out about a year later, when they saw a story on the news. The drug was vecuronium, a powerful paralyzer that is used to hold patients still during surgery.

Vecuronium is also part of the deadly cocktail used to execute inmates on death row.

“That’s the one thing that upsets me,” Gary said. “When I see it was a drug they use for lethal injection, I don’t know man – that’s just not right. I understand everybody makes mistakes, and I feel for the lady who is involved in this because I have a heart that takes after my mom, but it bothers us still.”

The circumstances of Murphey’s death were originally revealed in a November report from the Centers of Medicare and Medicaid Services, which said the federal agency might suspend Vanderbilt’s Medicare reimbursement payments if the hospital did not take steps to prevent future accidents. Vanderbilt quickly provided CMS with a corrective plan so the reimbursements were no longer in jeopardy.

The CMS report also said that Vanderbilt told the Davidson County Medical Examiner that Murphey suffered a natural death and that the medication error was “hearsay.” Vanderbilt officials have said the death was reported to the medical examiner within 40 minutes, before a “definitive conclusion” about the cause of death had been reached.

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Brett Kelman is the health care reporter for The Tennessean. He can be reached at 615-259-8287 or at brett.kelman@tennessean.com. Follow him on Twitter at @brettkelman.

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