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Elderly UPMC Patient Wanders Through Fire Exit, Dies On Roof

Woman With Dementia, Heart Disease Spent Night In Cold

POSTED: 7:16 am EST December 3, 2008
UPDATED: 5:59 pm EST December 3, 2008

An elderly patient wandered away from her hospital room and took a fire door to the roof, where she died after being outside in freezing temperatures overnight, Pittsburgh police said.

Police had been searching all night for Rose Lee Diggs, 89, who they said walked away from UPMC Montefiore in Oakland at about 5 p.m. Tuesday, wearing a blue hospital gown and slippers.

Lt. Kevin Kraus said Diggs, who suffered from dementia and heart complications, gained access to the roof after walking through a fire exit -- but an alarm did not sound.

"She left her room, walked through a nearby fire door, which was labeled a fire exit, proceeded to walk up a couple of flights of stairs, through another door, into a boiler room, then a third door out on the roof and she was found just outside that door," said Kraus.

After the woman was found early Wednesday, hospital staff brought her inside and tried unsuccessfully to resuscitate her, Kraus said. Police were called 45 minutes later.

"We were told that one woman did check the roof but she claimed the lighting conditions weren't that good, but she did advise the hospital personnel the roof was checked and Mrs. Diggs was not up there," said Kraus.

Police said someone checked the roof again at about 8 a.m.and found Diggs not far from the door.

Police have turned the investigation over to the district attorney's office to determine if any charges will be filed against hospital staff.

UPMC, which originally released the victim's name as "Biggs," issued the following statement Wednesday evening:

"We at UPMC are very saddened by the death of Mrs. Diggs and extend our deepest sympathy to her family. We are committed to the care and treatment of all our patients in a safe and caring environment. Our policies and training are designed to help our patients heal and to keep our patients safe. As a result of this tragedy we are undertaking a thorough review of all our policies and procedures in order to prevent a similar incident for another patient in the future. We are cooperating fully with the City of Pittsburgh Police Department in their investigation of this incident.

We have reported this incident to appropriate regulatory and government agencies and will seek their input in our ongoing review. Our thoughts are with her family at this difficult time."

That explanation was not enough for Diggs' family, who has since hired an attorney.

"The family is looking for us to try to get to the bottom of the situation to determine how their mother passed away in such a horrific manner," said attorney Rob Pierce.

"There was ample evidence that Mrs. Diggs needed adequate security because of the dementia she was suffering from. It appears the hospital should have known that she needed to be in a room with alarms incase she wandered."

Pierce said quick legal action is necessary.

"They want us to do everything we can with the courts subpoena power to help gather documents, preserve documents and evidence," said Pierce.

Diggs' cause of death has not been determined.

How Could This Have Happened?

UPMC did not answer questions regarding its policies and procedures regarding exit door at Montefiore Hospital.

They also did not comment on what is typically done to keep dementia patients safe.

However, Channel 4 Actions News Investigative Reporter Jim Parsons spoke with an expert on caring for dementia patients.

Watch Jim Parsons' Report

Ella Bostedo serves as the director of Arden Courts, a residential facility for people with Alzheimer's and other forms of dementia, in Monroeville.

Fire codes do not permit doors at Arden Courts or at Montefiore Hospital to be locked, but they are allowed to place a delay on them.

"There's a beep and that will continue to beep [when the door is forced open]. After about 15 to 20 seconds it will open, and then the alarm will sound in all of the houses," said Bostedo.

All doors leading to an outside area are alarmed.

Arden Courts has one resident who tries to get out every day, something that could spell trouble if the alarm key becomes disabled.

"She would be outside, yes. She would have no idea where she was going. She would believe she was catching the bus to go home," said Bostedo.

Arden Courts constantly re-evaluates its procedures.

Former UPMC trustee Paul O'Neill, also the former treasury secretary, said he hopes UPMC uses the tragic death of Diggs to re-evaluate its safety policies.

O'Neill is a promoter of hospitals learning from their mistakes, something he spoke about in an interview with Team 4 earlier this year.

"Every time we have an event, we learned something from it, we shared it with everyone, which is not something you find in medical institutions, and then you can put yourself on the road to improvement," O'Neill told Team 4 in January.

Bostedo offered three suggestions if a loved one with dementia enters a hospital.

First, make sure the hospital staff is fully aware that the loved one is not what is referred to as "safety aware."

Second, ask what the hospital's safety procedures are for a patient with dementia, including whether someone will sit with the patient at all times.

Finally, when in doubt, make sure a family member stays with the patient around the clock.


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