EASTPORT, Maine — More than eight years have passed since Reid Emery, a 61-year-old patient, was found dead in the snow outside a Machias hospital.
Now, with recent court proceedings bringing the case back into the spotlight, his wife and sister say it’s time for people to hear their side of the story.
“He was in a place where I felt he would be safe and taken care of,” his wife, Margaret Emery, said recently of the hospital.
On the night of Jan. 1, 2008, Reid Emery, who was on medications for severe abdominal pain and pancreatitis, for which he had been admitted five days before, sought to leave the 50-bed hospital against his doctor’s advice.
The nursing supervisor that holiday night, John Zablotny, evaluated Emery and found him competent to sign a standard form allowing patients to leave the hospital against medical advice. Zablotny discharged him at about 8:30 p.m.
Emery told Zablotny he was just walking a short distance to a friend’s house and left the hospital in a snowstorm wearing only jeans and a flannel shirt. His body was found the next morning beneath more than a foot of snow, about 380 feet from the main entrance of the hospital.
According to a medical examiner’s report, Emery died of hypothermia and opiate (fentanyl and Demerol) toxicity. The state medical examiner’s office said in 2008 there was no way to know whether Emery could have survived the cold if these drugs weren’t in his system.
The case drew widespread attention and was investigated by the state attorney general’s office and the federal Centers for Medicare and Medicaid Services, which found, among a number of other deficiencies, that hospital staff failed to meet their patient’s safety needs.
In response, Down East Community Hospital was downgraded to a conditional state operating license in 2008. After making quality improvements over the next two years, the hospital regained its full license in March 2010.
No criminal charges were ever filed, but in June 2010 Attorney General Janet Mills announced the Maine State Board of Nursing had revoked Zablotny’s license to practice for two years. Zablotny appealed, however, and in December last year a district court judge reduced his nursing license suspension to 90 days.
Emery’s state of mind
Reid Emery was a gentle man with a dry sense of humor who loved kids, especially his two sons and three grandchildren, Emery’s wife and his sister, Sally Emery, recalled as the two sat at the kitchen table of Reid and Margaret Emery’s Eastport home on Jan. 29.
Both are upset with some of the allegations made during recent court proceedings involving Zablotny.
Reid Emery never should have been allowed to leave the hospital given his condition, they said. Both women said they talked to him by phone just over an hour before he was discharged and found him to be confused and agitated.
“I’m not stupid,” Margaret Emery, who was married to Reid for 37 years, said. “I know when someone’s lucid and when he’s not. I don’t care what John Zablotny says.”
On Jan. 1, 2008, Margaret Emery called the hospital at about 7:15 p.m., first speaking to one of the nurses and then her husband.
For some reason, she said, Reid Emery thought he had AIDS. He did not. He was supposed to have a CAT scan but could not remember whether he had undergone one, she said.
“[As] I was trying to reason with him … the more agitated he became,” Margaret Emery said.
Sally Emery, who was in Ohio visiting relatives, also called and tried to reason with him, to no avail.
“I said, ‘You don’t have AIDS. Nothing has changed,’” Sally Emery said. “He said, ‘You love me, so you won’t tell me the truth.’”
Margaret Emery said one of the hospital nurses told her Reid Emery was suffering from “medically induced dementia.” She was told he would be OK in a couple of hours after the medications wore off, she said.
To try to control his pain, medical personnel had prescribed Dilaudid (hydromorphone), Demerol (meperidine) and a fentanyl patch, according to documents filed in Machias District Court.
Side effects of those opioid medications include drowsiness and impaired judgement.
Misplaced paperwork
During a hearing in May on Zablotny’s appeal of his license suspension, the nursing board did not argue that Zablotny shouldn’t have discharged Reid Emery. Instead, it argued Zablotny should have quizzed him more thoroughly about his plans, according to Machias District Court Judge David J. Mitchell.
In so doing, “the board … implicitly and explicitly conceded that Mr. Emery was physically and mentally competent to discharge himself,” Mitchell wrote in his December 2015 ruling.
Mitchell concluded that the nursing board lacked sufficient evidence to find that Zablotny was incompetent in the practice of nursing. The judge nevertheless found his conduct “unprofessional and highly disturbing,” warranting the 90-day license suspension.
Margaret and Sally Emery still can’t believe Zablotny sufficiently assessed Reid Emery that night to determine he was rational enough to discharge. They also dispute other statements of fact found by the judge, including that Reid Emery had a “tiff” with his family that day, which led him to ask Zablotny not to call them before discharging him.
They were just trying to reason with a heavily medicated Reid Emery, both women said.
“There was no fight with Reid. This ‘tiff’ — it didn’t happen,” Margaret Emery said.
Reid Emery didn’t mention to either his sister or his wife that he wanted to leave the hospital. He also failed to tell them he had told a nurse he wanted to get a gun and shoot himself because of the pain, the women said.
“Pancreatic pain is severe, probably the worst pain,” said Sally Emery, who is also a nurse, with the Veterans Administration Healthcare System in Calais.
Reid Emery suffered from COPD, or chronic obstructive pulmonary disease, constipation, emphysema and gastroesophageal reflux disease. He was underweight, standing 6 feet 4 inches tall and weighing only 145 pounds, according to court documents.
Margaret and Sally Emery are angry, they said, because COPD is made worse by the cold.
“There’s no way he could have made it from the entrance to the hospital to the road,” Margaret Emery said.
According to Judge Mitchell, Zablotny was not aware Reid Emery had threatened to kill himself until just before 9 p.m., after Emery had left. The nurse came across some of his patient paperwork, which had been misplaced by another hospital staffer.
Upon reading the paperwork, Zablotny immediately called 911 to alert police, the judge pointed out. The nurse also called Emery’s wife at 9:05 p.m. to inform her that her husband had left the hospital.
When Zablotny called her, she assumed her husband had been transferred to a facility in Portland, which he and his family had requested, she said. She asked which hospital he went to and how he was transported, she said.
“In this monotone voice, [Zablotny] said, ‘There’s no hospital. There’s no ambulance,’” Margaret Emery recalled.
She said she couldn’t comprehend what he was saying and hung up on him. Then she called right back and asked, “Are you telling me Reid has left the hospital on foot?”
Zablotny told her yes and that her husband had gone to visit a friend, she said.
“I said, ‘We’re from Eastport. He has no friends in Machias,’” Margaret Emery recalled.
Next, she told Zablotny to “go get [Reid Emery] back,” she said.
“Little did I know, Reid was already dead,” she said.
His official date of death is Jan. 2, but she believes he couldn’t have lasted more than an hour outside that night, she said.
Sometime after 9 p.m., hospital housekeeping staff found Reid Emery’s winter coat in his hospital room, Margaret Emery said.
By the time police got to the hospital, the snow was falling hard and there were no tracks to indicate where Reid Emery might be. They searched in front of the hospital and in the parking lot, but found no clues.
Court case continues
According to court documents, Zablotny had written on the discharge form that Reid Emery risked “deterioration of condition” by leaving the hospital against medical advice. The court ruled Zablotny should have informed Reid Emery he risked hypothermia and death.
Mitchell concluded that Zablotny also failed his patient by not telling him the hospital doors would lock behind him when he left and that he would not be able to come back into the hospital the same way he left.
“This court is deeply troubled by Nurse Zablotny’s refusal to accept at least some responsibility for his treatment of Mr. Emery and to acknowledge the errors he made on the evening of Jan. 1, 2008,” Mitchell wrote.
The state attorney general’s office argues the ruling doesn’t go far enough. It filed an appeal on Jan. 27, questioning the district court’s conclusion that Zablotny had no duty to notify the police; Margaret Emery, who was his emergency contact; or his physician upon the patient’s departure from the hospital. The appeal also takes issue with Zablotny’s failure to inform hospital administration of the circumstances of Reid Emery’s discharge and for failing to make a plan to ensure his patient’s safety.
A family haunted
Published reports have made Zablotny look like the victim in this case, Margaret Emery said.
Except for 108 days during which his license was suspended before his appeal, Zablotny has worked as a nurse at Mount Desert Island Hospital in Bar Harbor since January 2008, according to the court.
“John Zablotny is alive and working,” Margaret Emery said. “Reid’s dead.”
She pointed to another passage in the judge’s findings of fact, in which he said another hospital staffer expressed “some very real concerns” about Emery within five minutes of his discharge. When that staffer asked Zablotny whether he planned to call police, Zablotny declined, saying Emery hadn’t broken any laws, according to the court document.
The same staffer then asked Zablotny how Emery would get back into the hospital if he changed his mind, because the front doors were locked.
“Nurse Zablotny responded in a short and dismissive tone that ‘Emery could come back in through the ER and would come back in dead,’ or words to that effect,” the judge wrote about the exchange.
Zablotny’s attorney, Joseph Baldacci of Bangor, said this week he and his client have no further comment on the case.
“We have extended our condolences to the Emery family. Our thoughts and prayers are with them,” he said.
In September 2011, after sharing its plan with Margaret Emery, the Down East Community Hospital dedicated its Medical Associates Building in memory of Reid Wilder Emery “and to honor the sad sacrifice and lessons learned” by his death.
On Feb. 2, DECH spokeswoman Julie Hixon said the hospital had no comment about the case.
“We continue to keep the Emery family in our thoughts and prayers,” she said.
Neither the family nor the hospital will discuss whether they ever reached a financial settlement to avoid a lawsuit.
Margaret Emery and Sally Emery said they are haunted by the way Reid Emery died.
“I wonder … what could he be thinking as he’s dying?” Sally Emery said. “That’s what’s giving me nightmares.”