Family sues after hospital fails to notify of daughter’s death, records show she was discharged
Key Takeaways
A Sacramento hospital failed to notify the family of a woman who passed away in April 2023.
The family searched for over a year before being informed by county law enforcement of the woman’s death.
A lawsuit has now been filed against the hospital and its parent medical system.
Jessie Peterson passed away while she was a patient at Sacramento’s Mercy San Juan Medical Center.[] A death certificate completed in April 2024 revealed that she had died of cardiopulmonary arrest at the hospital in April 2023—after her family had spent over a year searching for her.
Jessie Peterson had type 1 diabetes. She was diagnosed at the age of 10 and was hospitalized around 20 times throughout her life.[] She was experiencing her third severe diabetic episode in the span of just a few months when she presented to Mercy San Juan Medical Center on April 6, 2023. According to her family’s lawyer, Marc Greenberg, Peterson at times experienced addiction and homelessness.
On April 8, 2023, Peterson called her mother, Ginger Congi, to ask for a ride home because she would be leaving the hospital.[] Mercy San Juan staff later informed Congi that Peterson had left the hospital against medical advice. Peterson’s medical records indicate that she was discharged on April 8, 2024.
Peterson’s family immediately began a search for her, reportedly spending months posting flyers, contacting the police and the coroner's office, and speaking to members of the local community.
An end to the search
Sacramento County detectives contacted the Peterson family on April 12, 2024, to inform them that Peterson had been found dead at Mercy San Juan Medical Center.[] According to the death certificate, issued on April 4, 2024, Peterson had died of cardiopulmonary arrest on April 8, 2023, at the age of 31.[]
California Health and Safety Code states that an attending physician must complete the information for death certificate filing within 15 hours of a patient’s death.[] No explanation for the delay in Peterson’s death certificate has been provided. Additionally, Congi was listed as Peterson’s next of kin. Hamdan Abdullah Hamdan, MD, a dermatologist who specializes in skin cancer, says that notifying a family member or other designated contact should be the first step after any death occurs at a hospital.
“Notifying the family or next of kin is crucial for both legal and emotional reasons,” Dr. Hamdan says.
Records show that hospital staff had been in frequent contact with Congi throughout Peterson’s stay. It is unclear why Congi was not informed of her death.[]
One of Peterson’s sisters went to the coroner’s office to retrieve her remains; however, when she arrived, an employee told her that Peterson’s remains were not there. She was told to contact the hospital. According to the lawsuit, Mercy San Juan did not respond to the family’s contact attempts. Staff at Sacramento’s East Lawn mortuary later told Congi that Peterson’s body was found in an off-site storage facility managed by Mercy San Juan.[]
Peterson’s body had been transferred to the off-site Mercy San Juan facility on April 9, 2023.[] Her body was reportedly badly decomposed by the time it was found a year later, and an autopsy could not be conducted. The family was unable to obtain fingerprints or hold an open casket funeral.[] According to Congi, Peterson’s identifying features, including her tattoos, were no longer intact.[]
“[M]eeting with people at East Lawn and learning that none of her tattoos could be identified on her body because her body was so discolored and so decayed, was very, very alarming,” Congi told local Sacramento news station FOX40.[]
Filing a lawsuit
Since an autopsy could not be conducted, there is no way to determine Peterson’s death involved medical malpractice. The lawsuit alleges, however, that Mercy San Jaun’s treatment of Peterson’s body, as well as its failure to inform her family, is “inexcusable negligence.”[] The complaint states that the defendants’ “failure to issue a timely certificate of death, failure to notify Jessie’s next of kin, failure to allow an autopsy, and mishandling of Jessie’s remains [was] negligent, careless, and heartless.”[]
The family is seeking over $5 million in damages, as well as attorneys’ fees and “five times the jury’s award of actual damages.”[]
Mercy San Juan is operated by Dignity Health, a large health system with hospitals throughout Central California. The company issued a statement that reads, in part, “We extend our deepest sympathies to the family during this difficult time. We are unable to comment on pending litigation.”[]
What this means for you
A provider’s responsibilities for a patient extend to proper and respectful care following death. These vital final regulations help to ensure the accuracy of patient data, while providing care to the recently deceased patient and their loved ones.
"Each step in this process ensures that the passing of a patient is handled with dignity, while also meeting all necessary legal and regulatory requirements," Dr. Hamdan says.
It can be good practice to know the protocol for handling patient deaths at your practice or facility, and to be aware of any regulations specific to your state.