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No one sent out a press release when two middle-aged men were fatally injured 13 days apart by a maze of mistakes at Los Angeles County Harbor-UCLA Medical Center.
Only a small knot of medical staff and government officials knew about the twin 2011 tragedies at the safety-net hospital south of Los Angeles, and they weren’t telling the public.
We probably wouldn’t know about the tragedies today except for a Medicare inspection report called a “2567” – the same kind of reports now available online for the first time at AHCJ’s website.
But we do know these stories because California public health investigators, acting on behalf of the federal government, arrived unannounced at Harbor-UCLA in September 2011 after the hospital notified them of problems there. They produced a report for Medicare that describes myriad errors and why they occurred.
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