Letter Sent to Duke’s Risk Assessment Manager John Legge – Re: False Medical Report Placed in Patient’s File

Posted on June 12, 2017

The following letter, dated May 17, 2017, was sent to John Legge, as well as those people copied upon this letter, last month.  I will be posting the letter that was mailed out that has the “false” narrative as to timeline of events and condition of patient which was  prepared by  “Kaitlyn Y” who was working with Hershel Cassell, MD during the early morning hours of August 13, 2011.

May 17, 2017

John Legge

Risk Management

Duke Regional Hospital

36 North Roxboro Road

Durham, North Carolina  27704


I am confident that by now that you are aware that Mark and I know about the false medical record placed in Mark’s file by registered nurse Kaitlyn Y. I discovered her false medical record creation she placed in Mark’s medical file this past January 2017. I am sure that you never thought that I would discover it. After all, Mark’s former attorney had failed to catch it as well as had his supposedly consulted “expert witness”.

I am sure that you remember when Mark and I met with you back in October of 2014.   It was to discuss our request for a settlement for the injuries caused to Mark by the ciprofloxacin and tizanidine adverse event. That adverse event occurred because of a medicine error made by a Duke Raleigh Hospital ED doctor. I remember how cocky your remarks were and your confidence in being so sure of your “facts” and your position.

Remember how you looked at me when I told you that we would settle for $156,000? Do you recall your smug reply to my request? I most certainly do. You said, “Why should I settle this case for $156,000, when I could have settled it on two different occasions for $60,000?”   I said, “What?” And your reply was that our former attorney had offered to settle Mark’s case for $60,000 on two different occasions and you had turned him down. Did you enjoy the stunned look on our faces? You then followed up on my $156,000 request by saying, “How did you come up with your figure [$156K]?”

The answer to that question was that I wanted to be fair.  Our former attorney, for whatever intents and purposes, had tossed Mark’s case under the bus when you turned down his second request for $60,000. Since we were not going to incur the expense of having to pay an attorney, I was deducting the amount of a legal fee from $200,000. An attorney had shared that number with us when we had talked with him about taking over representation of Mark’s case. This attorney suggested that the value of Mark’s kidneys injury would be around $200,000.

At that meeting I gave you a notebook containing medical facts about Mark and the two medicines that had potentiated in his body, a letter from Mark’s doctor, the EMS documentation that you said our former attorney had not furnished to you and articles stating the toxicity that occurs when ciprofloxacin and tizanidine are taken together. That letter, written by Mark’s doctor, stated that up until the adverse event caused by Dr. Plonk’s medicine error, Mark’s kidneys had been healthy. There was a complete series of tests results from UNC Hospital also in that same notebook, showing just how healthy Mark was before his experiencing the ciprofloxacin and tizanidine adverse event caused by your doctor’s medicine error.   It was our hope that we might at least recover some of our savings that we had spent caring for Mark during his recovery from the ciprofloxacin and tizanidine adverse event.

Honestly, how in the world did you keep from falling out of your seat laughing at us? There we were, sitting with you, trying to offer reasons why you should grant our request to come to a financial settlement for Mark’s injuries. At the time of our meeting with you we had spent almost our entire savings caring for Mark, paying his medical bills and our living expenses. Several attorneys had turned down Mark’s case on the sole reason of, to quote, “I just don’t want to deal with Duke.”

You asked us this question. “If I agreed to your settlement amount, what would you do with the money?” That question, which you knew that you had no right to ask caught me so off guard that I had to stammer for an answer. I think my reply was along the lines of “well, I would use it to take care of my husband, make our house better, build a new bedroom, take care of our bills, etc., stammer, stammer, stammer.”

You ended our meeting shortly afterward with the usual “we will review the information and get back to you with an answer” statement. As we were leaving, I looked back at you. Something did not feel right but I did not know what it was. You had a look on your face that was both detached and dismissive at the same time. Mark didn’t see it but I did. I did not talk much to Mark about what I saw or thought after meeting with you. At that time, his physical, mental and emotional health status was so fragile that I didn’t want him to worry.

When you finally called with your refusal to compensate Mark for his injuries both Mark and I were stunned. Barbara Hendrix, who is now no longer with Duke Risk Management, sent out her usual hatchet letter denying our claim. She strung together the worn out pre-existing lines as her reasons for denial, but it was all puff and no fact. Like many others in her profession she refused to recognize that the events closest to the onset of a health crisis are the ones most likely to be responsible for the crisis.

In thinking about this now, I wonder if you went home that day, satisfied in the knowledge that you had and which we did not have. You had to have confidence in the fact that Kaitlyn Y’s creative false medical report that she had placed in Mark’s medical file would keep anyone from discovering the real truth of what had happened to Mark at Duke Raleigh Hospital ED early on that Saturday morning back in August 13, 2011. By Kaitlyn’s falsifying Mark’s medical condition as an opiate overdose, you knew that her false medical record would conceal the medical error committed by Dr. Plonk.   As I stated at the start of this letter, it had already escaped discovery by Mark’s former attorney and had been overlooked by that attorney’s supposedly consulted “expert witness”.

The devastating ciprofloxacin and tizandine enhancement adverse event was not mentioned anywhere in Mark’s Duke Raleigh ED or inpatient file. You were so confident in the concealment of Mark’s true condition that you and I dare say Barbara Hendrix, felt there was no reason to reimburse Mark for any costs he had incurred because of Dr. Plonk’s medicine error.

Before you start to use the protest that you were not aware of any false medical record in being placed in Mark’s file, let me remind you of this. You have worked for years in the field of hospital risk management. It is YOUR JOB to know the facts of what is placed inside of any patient file that winds up on your desk. It is your job to see that hospital personnel clearly understand the gravity of the situation created for the hospital when anyone seeks to falsify a patient’s medical information. Medical providers have a sacred duty to be truthful in their reporting of their patients’ medical events and treatment plans.   A patient’s medical file will follow them for the rest of their lives. Future treatment plans will be based upon the documentation held in those files. If false medical records are present in a patient’s file, it can hold disastrous consequences for both patient and doctor.

Personally, had I have been your boss and this situation would have occurred on my watch; I would have fired you in a New York second. Then again, perhaps Duke still might fire you. After all, none of this should have been allowed to occur. Just think about this.  You had been given three offers to settle Mark’s case for a lot less than the $267,426.22 that Mark and I had spent out of his savings account.   You were so cocky that you turned those offers down. You mistakenly thought that no one would ever discover the false medical record in Mark’s medical file. By believing that, you have allowed a huge can of worms to pop open for Duke Raleigh Hospital, plus the doctors and hospitals that have treated Mark since. Even the doctors that are currently treating Mark now have been affected by their recent knowledge of this criminal cover up.

Remember when I told you that someday, people were going to see that the “Emperor” [Duke] had no clothes on? Well, that day has now dawned.  You have no idea as to the sympathy that Mark is getting from some of his medical providers. It is my sincere hope that as I continue to contact parties who might want to know about what happened to Mark, that other hospital systems will look at this example of what happened to my husband as a example of how NOT TO DO RISK MANAGEMENT.

I have notified a herd of doctors, two hospitals, our former attorney’s law firm, several other attorneys we had spoken to when trying to find a replacement attorney to take over Mark’s case along with the presidents of both Duke and Duke Raleigh Hospital. I have filed a report of this crime with the Federal Bureau of Investigation. A letter requesting the full name of nurse Kaitlyn has been mailed to the Director of Nursing at Duke Raleigh Hospital.   I promise you I will be getting that nurse’s name.   If I have to look all over Hell and half of Georgia, nothing will keep me from getting Kaitlyn’s last name.

I want to see this nurse answer for her criminal action. Kaitlyn Y’s creation of that false medical record hurt my husband in his communication attempts with doctors consulted by him for continuing post-injury care of the ciprofloxacin and tizanidine adverse event. It slammed the legal door shut as to his getting any compensation for his injuries caused by that ciprofloxacin and tizanidine adverse event.   Kaitlyn Y should face legal consequences for her actions in falsifying and confirming as truthful by her signature and initials, Mark’s medical treatment at Duke Raleigh ED during the hours and minutes of 01:23 AM through 06:33 AM on the date of August 13, 2011.

Unlike the scenario of an opiate overdose, the real adverse event of a hugely potentiated dose of tizanidine in Mark’s body did not leave his body unscathed. The extreme hypotension and the extended time that he remained that way left his once healthy kidneys and thyroid permanently damaged. The hypotension caused Mark’s body to experience a hypoxic state. The hypoxia caused brain injuries, one of which was a more severe type of apnea than the obstructive sleep apnea Mark had previously been diagnosed with. Mark now has central apnea, which is less common and more dangerous to him than obstructive apnea. The central apnea is severe enough that Mark is now on nightly supplemental oxygen.

Mark now suffers from cognitive short-term memory problems. Mark’s vision was greatly hampered. It was hard for him to read print and focus on its meaning. Thankfully, as of 2015, it has steadily been improving. The hearing loss he experienced is permanent. He now wears hearing aids.

According to the drug manufacturer, Mark is the only known living survivor of a potentiated dose of 12 mg of ciprofloxacin and tizanidine. True to His Word, God is healing Mark and will be bringing about a restoration of all that he has suffered both financially and emotionally from his devastating injuries. The last near fatal event for Mark occurred in June of 2015. Since then, we have been able to see Mark start on a path that looks to be recovery focused. In 2016, after several near death experiences in previous years, Mark had a great year. This year of 2017 looks to be another great year of continued recovery and learning to live with the permanent damage caused to his body by that deadly drug combo. Additionally 2017 is also a Jubilee Year. It would be fitting that this year is the year in which Mark is to be restored both physically and financially.

In order to help others who are being contacted about what happened to Mark at Duke Raleigh Hospital, I created a ready access to certain resources, i.e.: a secure web link with password access.   Mark’s medical records, FDA cases, research articles, etc., are resources that can be found there.   A copy of the letter from Dr. Kunstling is in the database. The original complaint letter mailed to Dr.Kunstling and others, along with several FDA cases are in the process of being scanned and uploaded to the information database, i.e.: FDA – Adverse Event Reporting System (FAERS) Case ID: 9683355 is Mark’s report that I filed. Under “Event Information” only the myocardial infarction DID NOT occur. I had referred to Mark as seated in a “dead man” position as if he had suffered a heart attack. Mark is very fortunate to have a very healthy heart. If he had not had one, there would have been no chance at all for his surviving the last five years.

The webpage is https://wheredidtheoldmego.com/records/  Password : Isaiah4031 Note: some personal letters sent by me to certain parties are NOT available in the database.

You have probably by now noticed that your letter was not sent to you as a certified letter. Certification is not necessary for this letter. It will be placed as an open document on my website.

John, I truly believe that you thought that Mark would crawl off and die. You were so sure that I would be so broken by his death that the cover-up crime committed against Mark would have never been discovered. Happily for us, it didn’t happen. Mark has been able to start carving out a new post-injury life for himself. Our marriage has survived the hell your doctors and nurse Kaitlyn Y put us through. We are now daily walking out of that abyss and into a time of new days, bright with promise.

I have noticed before that you don’t particularly care for my talking about God. You got a kind of squirmy look in your eyes when I mentioned His name during our time of meeting with you in October of 2014. However, you cannot deny His involvement in bringing the inconvenient truth out as to all that happened to Mark when he was at Duke Raleigh Hospital.

That is why I know that you will not remain in your current job. Whether your leaving is caused by a termination by your employer or other life events, I truly believe that God will not allow you to continue to do to others as you have done to Mark.   During the horrible years when Mark was so very sick and so mentally and emotionally injured, I swore to God that I could never forgive what you had done to us. I told God that if He wanted me to forgive you and the others, He was going to be disappointed because I simply could not do it.

As the years went by I continued to research ciprofloxacin and tizanidine adverse events information. My notes piles were growing taller. I signed up for James Patterson’s writer’s course. I continued writing and researching, taking Mark to doctor’s appointments and using our savings to provide as normal a life as I could for our family. We found a new church family. What was broken in me started to heal. Since that time, lots of healing both in Mark and in me continues. Returning to the ways of praying and forgiveness of others is becoming easier.

Mark has continued healing and adapting to his new life changes. Mark was able, this year, for the first time since his injuries suffered because of your doctor’s medicine error, to drive himself into Raleigh to one of his doctor’s appointments. Think about that, John. This man had held a CDL license for over 30 years. He worked and retired from Progress Energy in 2005 with 35 years of service. From that day in August 2011, when I asked Dr. Cassel if my husband was going to die, Mark has literally walked out of his grave and is now living with his disabilities.   What had once been thought to be a death sentence has now been proved to be a survivable health crisis. When I think about the last five years since the medicine error, I always think of the 23rd Psalm. Mark walked through the valley of the shadow of death and God was faithful. God is always faithful.

When I went into my office in January of this year, it was with the intention of packing up the boxes of copies of records and files that had accumulated over the years. There was an envelope lying on the worktable. I had though it contained duplicate copies and had not opened it. Next to it was a copy of the four pages Nursing Flowsheet document.   True to my nature, I picked up the document and started to read it again and boom, there was the truth staring back at me. I must say that I rate the discovery of that information right up there with the birth of my children.

For anyone to think it logical to ignore the truth of what happened to my husband at Duke Raleigh Area Hospital on August 12 & 13, 2011, thinking that it will make it “go away” there is another thought coming. I promise you that the “another thought coming” will be “ How did you, John, let this situation get out of control? Whose bright idea was it to try to cover this up and WHY is that person still working here at our hospital?” Just think about it, John. You will be the lucky person who gets to answer those three questions. If you feel confident that Duke Hospital personnel won’t ask you those questions, get real. If they don’t, Duke alumni will. Alumni really don’t like it when people working for their Alma Mater, people who should have known better, screw up. Plus, they are going to be as hot as all get out when they find out the medicine error cover up was done by a criminal act committed by Kaitlyn Y.

John, you had a chance to hide all of what I have shared with you for a measly $156, 000. I’ll bet that number looks pretty cheap now, doesn’t it? Pretty cheap for a criminal cover up of what happened to my husband Mark at Duke Raleigh Area Hospital ED. It would have been a pretty cheap price for leaving my husband with devastating injuries and fighting for his life. It’s a bargain basement price for nearly destroying a family.

This month, with our savings exhausted, the 16th of May came and found us without our house payment. With only a little over three years to go, on a perfectly paid on time mortgage, I had to notify the bank that we do not have the monthly payment. I don’t know what will happen with that but I do know that God is faithful. Now that Mark has sufficiently recovered enough for me to return to the workforce, my attempts to find work have not been successful, but I continue to search for work. While I am searching I am writing. John, you have to admit it. Our story is unique. Paperwork missing, attorney screw-ups, hospital lies and a nurse creating a fake medical record and placing it into the patient’s file. Patient survives the previously thought non-survivable medicine error only to be broadsided by those who want to make sure he doesn’t see his day in court.   Attorney throws client patient under the bus because you, John, won’t pay $60,000 to settle his client patient’s case. Over a quarter of a million dollars in patient’s savings have been exhausted, leaving the patient’s family facing financial devastation. Trust me John, this would make one hell of a great movie.

Thankfully I am coming to the end of this letter. Is the reality of what you have been a part of and have allowed to happen finally dawning on you? It won’t do you any good to say that it was Barbara Hendrix’es decision because you knew what was at stake. You knew back then what Mark and I did not know. The knowing of it cannot be logically denied by you. You had a duty to protect the hospital and you failed. You were the one closest to the event when it happened. Remember what I said on page 4 of this letter? That statement also applies to people. You were the person closest to the event. That one fact will be as plain as day to anyone who reads about this. It would not surprise me to see it being used as an example of how to not do hospital risk assessment management.

That’s the thing about people like you. People like me can be trained to do your job and we will do a better job of doing it. However, there’s no way to cross-train you to do my job. My job requires common sense and a heart, which are two items that you don’t seem to have in ready supply.  Personally, Duke Hospital would be better served by having me work for them in their hospital risk assessment group. You can bet your bottom dollar that medical screw-ups like the ones that hit my husband and our family would never get the kind of treatment that you gave our case. So, seeing as how I need to make a house payment, buy groceries, pay household and Mark’s continuing medical treatment bills, how about getting them to give me a job?

Dianna Carter

Attachments:   DRAH-ED Nursing Flowsheet [four pages]

Zhu, He, Childers, Diana; Toxicity of Tizanidine (Zanaflex) Exacerbated By Coadministration of Ciprofloxacin: A Case Report and Literature Review [abstract]. Journal of Hospital Medicine 2012;7 Supp 2:303  

Documents are available at webpage address https://wheredidtheoldmego.com/records/  Password : Isaiah4031 Note: some personal letters sent by me to certain parties are NOT available in the database.


cc:   A. Eugene Washington, MD, MPH, MSc

David Zaas, MD

Priscilla Ramseur, DNP, RN, CNOR, NEA-BC

Hershell Cassell, MD

Scott Gersh, MD


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