The Office of the Inspector General has released a report on its investigation of the medical care that PCV Nick Castle received while serving in China. To read the report, here is the link: OIG Report on Medical Care of Castle
We were able to obtain the actual report because the Office of the Inspector General has released the report to the public. We made a FOIA or Freedom of Information Request in order to get the report as soon as it was published. The Summary of Findings is taken directly from the report.
Here is a Summary of the Results from that report. I converted the PDF into a word document, so it may be difficult to read. The actually report is 32 pages long. There is a Synopsis in the beginning of the report. This Summary of Results begins on about page 30.
Summary of Results
During OIG’s investigative review of the facts and circumstances surrounding the death of PCV Castle, we interviewed more than a dozen witnesses and reviewed and translated medical records regarding PCMO Gao’s treatment of PCV Castle in October 2012 and January 2013 for gastroenteritis. In addition, we reviewed the agency’s sentinel process and retained a medical expert to review the care provided by the Peace Corps.
A thorough review of the case indicates that the rapid decline in PCV Castle’s health that led to his death was uncommon in an otherwise young, healthy individual. OIG’s review concluded that PCMO Gao failed to use prudent judgment in her treatment of PCV Castle in the morning of January 28 despite his multiple symptoms of dehydration/hypovolemia. She ordered ORS and other fluids, but failed to reassess PCV Castle during the next four hours.
OIG’s review also concluded that in the afternoon of January 28 there were cascading failures and delays in the treatment of PCV Castle. Upon entering PCV Castle’s room, PCMO Gao did not recognize the situation was critical. PCMO Gao did not immediately call for an ambulance despite signs of dehydration/hypovolemia, and a warning from a fellow PCMO that PCV Castle needed an IV “in 30 minutes or he is going to die. “Rather, she asked a different PCMO to come to the hotel, for IV fluids to be brought from the post medical unit, and for a post driver to transport the IV to the hotel, without informing the driver that it was an emergency situation.
When PCMO Gao finally called for an ambulance, she failed to convey his critical condition, telling the first responders that PCV Castle needed to go to the hospital because he had had diarrhea for several days.
OIG’s review also determined there were significant failures with the care provided by the Chinese ambulance EMTs. The EMTs failed to control the situation both in the hotel room and in the ambulance. At the time of PCV Castle’s transportation, he required his airway to be protected, adequate oxygenation, and a significant amount of IV fluids. Our review found that the EMTs likely did not intubate PCV Castle or use a laryngeal mask airway on the scene or in the ambulance. The EMTs focused on starting an IV while the PCMOs singularly focused on positioning PCV Castle on his side to protect his airway from obstruction. This conflict interfered with the response and continued in the ambulance as the EMTs attempted to start an IV. OIG’s review concluded PCV Castle probably succumbed to insufficiently treated hypovolemic shock and dehydration resulting in cardiac arrest that was associated with viral gastroenteritis fluid volume loss from vomiting and diarrhea.
OIG’s review also uncovered additional information, which while not contributing to PCV Castle’s death, did indicate PCMO Gao failed to adhere to several Peace Corps guidelines regarding medical chart record-keeping, including:
- documenting all clinical contacts with PCV Castle in the medical chart
- preserving an email sent to her by PCV Castle concerning his weight in his medical chart, and preservlng and translating medical records concernlng an earlier ER visit at his site.
OIG also uncovered that PCMO Gao altered PCV Castles’in-service notes after submitting them to Peace Corps headquarters for review, PCMO Gao resigned from her position on September 5, 2914.