Ra Donda Vaught-timeline

HEALTH The RaDonda Vaught case is confusing. This timeline will help. RaDonda Vaught, a Tennessee nurse, is the central figure in a criminal case that has captivated and horrified medical professionals nationwide. Vaught, 36, of Bethpage, has been criminally indicted on abuse and reckless homicide charges after she allegedly gave a patient the wrong medication, leading to her death. Many say they fear her case could set a precedent of prosecuting medical professionals for honest mistakes, so the case has become a rallying cry for nurses. But Vaught’s case is also confusing. The story of this fatal error spans three years, two legal proceedings and at least three investigating agencies. Many of the facts of the case were initially obscured from the public, and details that trickle into the public sphere are often incomplete and out of order. This timeline, which combines reporting from more than a dozen Tennessean stories and hundreds of pages of county, state and federal investigation records, is an effort to help it all make sense. A fatal medication mistake October 2015 — RaDonda Vaught, a licensed nurse, begins working at Vanderbilt University Medical Center, the largest hospital in Nashville and one of the most respected hospitals in the nation. Dec. 24, 2017 — Charlene Murphey, 75, a long-time resident of the Nashville suburb of Gallatin, checks into Vanderbilt with a subdural hematoma, or bleeding in her brain. Dec. 26, 2017 — Murphey’s condition improves and she is almost ready to leave Vanderbilt. During a final scan in the hospital’s radiology department, Murphey is supposed to be given a sedative, Versed, but is accidentally given a dose of vecuronium, a powerful paralyzing medication, according to a federal investigations report. The drug leaves her brain dead. Vaught allegedly admits to hospital staff she is responsible for the medication error. Dec. 27, 2017 — Murphey’s family gathers at Vanderbilt to say goodbye. She dies at about 1 a.m. after being disconnected from a breathing machine. Later that day, two Vanderbilt neurologists report Murphey’s death to the Davidson County Medical Examiner without mentioning the medication error or vecuronium. Murphey’s death is attributed to bleeding in her brain and deemed “natural.” Based on information provided by Vanderbilt, the medical examiner does not independently investigate the death. SOURCE DOCUMENTS: See what Vanderbilt told the Medical Examiner about Charlene Murphey January 2018 — In the wake of Murphey’s death, Vanderbilt officials take several actions that obscure fatal medication error from the government and the public. The error is not reported to state or federal officials, which is required by law, or the Joint Commission, an accrediting agency that recommends but does not require reporting. Vaught is fired by Vanderbilt University Medical Center. Early 2018, exact date unknown — Vanderbilt negotiates an out-of-court settlement with Murphey’s family that requires them not to speak publicly about the death or the medication error. The settlement is not publicly known. May 2018 — Vaught begins working as a “throughput coordinator” at TriStar Centennial Medical Center in Nashville, according to state records and her LinkedIn account. This is not a clinical position, but it does require a nursing license, records say. Oct. 3, 2018 — An anonymous tipster alerts state and federal health officials to the unreported medication error that was responsible for Murphey’s death. SOURCE DOCUMENTS: Read the anonymous complaint about the fatal error Oct. 23, 2018 — The Tennessee Department of Health, which is responsible for licensing and investigating medical professionals, decides not to pursue disciplinary action against Vaught. In a letter to Vanderbilt, the agency’s investigations director says Vaught’s case “did not constitute a violation of the statutes and/or rules governing the profession.” On the same day, Vaught is sent a letter saying “this matter did not merit further action.” SOURCE RECORDS: Read the Department of Health letters that cleared RaDonda Vaught Oct. 31 to Nov. 8, 2018 — In response to the anonymous tip, the Centers of Medicare and Medicaid Services conducts a surprise inspection at Vanderbilt. The inspection confirms that Murphey died from an accidental dose of vecuronium and that Vanderbilt did not report the medication error to the government or the medical examiner, according to an inspection report. RaDonda Vaught’s case goes public Late November 2018 — The circumstances of the fatal mediation error become public for the first time. CMS releases an investigation report that details the error without identifying Vaught or Murphey. CMS threatens to suspend Vanderbilt’s Medicare payments, crippling the hospital’s revenue, if Vanderbilt can not prove it has taken steps to prevent a similar error. Vanderbilt quickly responds with a “plan of correction” that appeases the federal agency and secures its Medicare reimbursements. Vanderbilt declines to release the plan of correction, although The Tennessean later obtains it through a public records request. SOURCE DOCUMENTS: Read Vanderbilt's plan to prevent another deadly error Feb 4., 2019 — RaDonda Vaught is publicly identified for the first time when she is arrested on a criminal indictment for her alleged role in Murphey’s death. She is charged with reckless homicide and impaired adult abuse. Court documents also reveal Murphey’s identity for the first time. In an interview with The Tennessean, Murphey’s family members say she would forgive Vaught. Feb. 5, 2019 — Vanderbilt executives speak about the fatal error during a meeting of the Tennessee Board of Licensing Health Care Facilities, which is responsible for disciplining hospitals. Vanderbilt Health System CEO C. Wright Pinson admits the death wasn't reported to state regulators and said the hospital's response was “too limited.” Vanderbilt officials also confirm for the first time that they negotiated a settlement with Murphey’s family. The board takes no disciplinary action against Vanderbilt. Feb 8, 2019 — In a GoFundMe post to raise money for her legal defense, Vaught appears to admit she made a mistake but does not elaborate. “Many feel very strongly that setting the precedent that nurses should be indicted and incarcerated for inadvertent medical errors is dangerous,” she wrote. (As of Feb. 24, 2020, this GoFundMe has raised more than $100,000.) Feb. 20, 2019 — Vaught makes her first appearance in court in her criminal case and enters a not guilty plea to all charges. The court hearing is attended by several dozen nurses, some of whom have traveled from outside of Tennessee to show their support for Vaught. After the hearing, Vaught’ criminal defense attorney, Peter Strianse, insists that Vanderbilt shares blame for Murphey’s death. "I think when this case is tried, and the facts come out, it's a mistake and it's not all of her fault either," Strianse said. "There are some real systemic problems with the way they dispense medicine through that automatic dispensing system." March 27, 2019 — In court records, prosecutors reveal far more details about Vaught’s case. Investigators allege that Vaught made 10 separate errors when giving the wrong medication to Murphey, including overlooking multiple warning signs that she had the wrong medication. Court records state that Vaught would have had to look directly at a warning saying “WARNING: PARALYZING AGENT” before injecting the drug. Court documents also say that Vaught admitted her error to investigators. SOURCE DOCUMENTS: Read prosecutorial discovery filed against RaDonda Vaught August 20, 2019 — At the request of law enforcement, Nashville Medical Examiner Feng Li re-examines the circumstances of Murphey’s death. Now aware of the medication error, Li changes Murphey’s official manner of death to “accidental.” Health officials reverse decision not to punish Sept. 27, 2019 — The Tennessee Department of Health reverses its prior decision not to pursue professional discipline against Vaught. Agency officials charge Vaught with three infractions before the Tennessee Board of Nursing. The agency refuses to explain why it reversed its prior decision. Vaught is charged with unprofessional conduct, abandoning or neglecting a patient that required care and failing to maintain an accurate patient record. Charging documents say Vaught could face thousands of dollars in fines and suspension or revocation of her nursing license. SOURCE DOCUMENTS: See the professional charges filed against RaDonda Vaught Late October to mid-November, 2019 — Because Vaught is now facing two legal proceedings — a criminal trial and a professional discipline hearing — a debate begins over which case should proceed first. Vaught’s attorney attempts to delay the discipline proceeding until after her trial, arguing that if she defends herself by testifying in the discipline hearings, prosecutors may use that information against her at trial. However, attorneys for the health department oppose this delay, insisting that Vaught is an urgent “threat” to the public. Much of the health department’s argument hinges on Vaught’s job at Centennial Medical Center, where she still works as a throughput coordinator. An administrative judge, Elizabeth Cambron, decides not to delay the proceeding, saying Vaught’s desire to delay the hearing is “outweighed” by the "seriousness of the allegations against Ms. Vaught." Dec. 15, 2019 — A Tennessean investigation reveals how actions taken by Vanderbilt officials obscured the circumstances of Murphey’s death, delaying and hampering an investigation into the hospital. The story also includes the first public statements from Charlene Murphey’s grandson, Allen Murphey, who is not constrained by the confidentiality agreement signed by other family members. “A cover-up — that’s what it screams,” Allen Murphey said. “They didn’t want this to be known, so they didn’t let it be known.” Vanderbilt declines to comment. Spokesman John Howser said the hospital would not speak further about Murphey's death "to avoid impacting either our former employee’s right to a fair trial or the district attorney’s ability to pursue the case as he deems necessary and appropriate." Jan 16, 2020 — Vaught’s attorney files a motion asking a county judge to overrule Cambron and delay the discipline proceeding until after the criminal trial. As of Feb. 25, a judge has not ruled on this request. May 20-21, 2020 — Vaught’s professional discipline hearing is scheduled at a quarterly hearing of the Tennessee Board of Nursing. July 13, 2020 —Vaught’s criminal trial is scheduled to begin. Spring, 2020 — The coronavirus pandemic delays both Vaught's professional discipline hearing and her criminal trial. Feb. 24, 2020 — Vaught's professional discipline hearing is scheduled to begin at a meeting of the Tennessee Board of Nursing. It is unknown if arguments will be completed during this meeting or continue at a subsequent meeting. May 27, 2021 — Vaught's criminal case is scheduled to hold its next hearing.