A woman died because a nurse gave first responders someone else’s do-not-resuscitate order, according to a lawsuit filed Monday in Superior Court.
Judith Englehart of West Hartford had been transferred to The Reservoir , a West Hartford rehabilitation center, after a hospitalization, according to the lawsuit filed by Sherri Englehart-Shea, administratrix of Englehart’s estate.
The suit was filed in Hartford court against The Reservoir, also known as Autumn Lake Healthcare, and the registered nurse on duty.
“It’s hard to understand how such a clear and tragic mistake could happen,” said attorney John J. Houlihan Jr. of RisCassi & Davis of Hartford, who is representing Englehart-Shea.
“For situations like this one, a patient’s code status should always be clearly visible on their medical chart. It’s inexcusable that this deadly oversight was allowed to occur,” Houlihan said.
Englehart, 77, suffered from chronic obstructive pulmonary disease and required breathing treatments. She was admitted to The Reservoir on Aug. 28, 2023, according to the lawsuit, as a “full code patient,” meaning she elected to receive cardiopulmonary resuscitation if needed. She was given a room with another resident.
On Sept. 4, Englehart needed a breathing treatment but became unresponsive, the suit states. A licensed practical nurse “began performing sternal rubs” and informed the registered nurse, who told the LPN to stop because Englehart had a DNR, according to the suit.
According to the National Cancer Institute, a do-not-resuscitate order is a “type of advance directive in which a person states that health care providers should not perform cardiopulmonary resuscitation (restarting the heart) if his or her heart or breathing stops.”
In Englehart’s case, the registered nurse dialed 911 “and asked if she were required to call 911 for an unresponsive patient with a DNR order,” the suit claims.
Police and fire personnel were dispatched and asked for the DNR order, the lawsuit claims. When the registered nurse did not promptly produce one, the first responders began CPR.
The registered nurse then produced a DNR order, but, according to the lawsuit, it belonged to the other resident in the room. “Resuscitative efforts failed,” and Englehart died at about 10:07 a.m., the suit states.
Her obituary described Englebart as “a successful real estate agent, a 20+ year Advanced Director position with The Pampered Chef, a talented artist and Certified ZenTangle Instructor.”
She worked at the state Department of Labor, was a mother, grandmother and great-grandmother, “a foodie who loved to create delicious dishes for her loved ones, a thoughtful and generous gift giver, a lover of all animals, a beloved member of The Universalist Church of West Hartford, and the greatest at a good pun,” the obituary said. “She was a giver, an empath, and a seeker of justice.”
The lawsuit claims staff at The Reservoir, including the registered nurse, “deviated from the applicable standard of care” in treating Englehart as though she were a DNR patient, failed to initiate life-saving measures, including CPR, failed to use a defibrillator and failed to call 911 when Englehart was found unresponsive, and failed to confirm Englehart’s identity, code status and medical chart.
Requests for comment were sent to both A Place for Mom and The Reservoir.
Ed Stannard can be reached at estannard@courant.com .
Editor’s note: This story has been edited to remove a reference to A Place for Mom.
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