A stench of corruption hangs over the whole debacle of the trial and sentencing of nurse Redonda Vaught. She was the designated scapegoat for a vast system of corruption. Vaught is Lt. William Calley in Vietnam, Dr. Anna Pou in the aftermath of Hurricane Katrina, Kareem Sarageldin after the 2009 financial meltdown. She could have been sentenced to eight years.
An unsatisfying justice prevailed. Vaught will not go to jail.
The livestreamed sentencing hearing may not have gotten ratings as high as the Johnny Depp and Amber Heard libel trial. But it will have more far-reaching implications. It energized the nursing world and called attention to crucial issues that need to be addressed a settings more appropriate than the criminal courtroom.
The nurses who stood in the courtyard or commented on the livestream or made TikTok videos (#RadondaVaught) understood what was at stake. A collective sigh of relief went up when, instead of prison, Vaught was given three years of probation on a diverted sentence. It was as close as the court could come to an apology. Vaught should never have been charged with a crime. She should not have been convicted.
Vaught is a scapegoat. The error that she made was almost inevitable in a hospital with a deeply flawed safety system.
Vaught promptly reported her error. That is tough to do. Physician David Hilfiker, in an essay entitled “Facing Our Mistakes,” observed that doctors who make mistakes often “either deny the misfortune altogether or blame the patient, the nurse, the laboratory, other physicians, the system, fate – anything to avoid our own guilt and pain.”
Vaught accepted accountability. She promptly reported her error and was instructed to cover it up. The doctors and hospital covered up the medication error. The hospital attributed the patient’s death to natural causes. They did not report the error to federal officials as required by law. They settled with the family.
Vaught was fired a week after the error. The Tennessee Department of Health investigated and concluded that Vaught should not even lose her license, much less be charged with a crime. They thanked her for her cooperation and noted, “This is not a disciplinary action. No notice of it will appear in your licensure file.”
But then an anonymous tipster notified the federal Centers for Medicare and Medicaid Services (CMS). A CMS investigation led to a 56-page report that found numerous safety violations at Vanderbilt University Hospital. Vanderbilt was put on probation and could have lost their Medicare reimbursements. Once that report became public, the District Attorney, Glenn Funk, who is on the faculty at Vanderbilt, brought criminal charges against Vaught. The DA office dug up dirt on Vaught. The Tennessee Department of Health reinvestigated and, at a contentious, tear-filled hearing, reversed their earlier conclusions about the case and revoked her nursing license. Vaught was being set up to take the fall.
Medical errors are the third leading cause of death in the United States. The way to improve quality and safety is not to slaughter a scapegoat but, instead, to reward the front-line workers who identify safety violations. Vaught did that, offering the hospital an opportunity to analyze root causes and change the system so that others would make similar mistakes. For that, she lost her job, her license, and was convicted of negligent homicide. It will take a while for the stench of corruption surrounding this miscarriage of justice to clear.