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Patient death leads to questions about emergency care at South Park Ambulance District

Sources say hidden documents, medical records tell another side of the story
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Editor's note: This is the second installment of a two-part series regarding the South Park Ambulance District. See part one here.

HARTSEL, Colo. — A call for help in the middle of the pandemic resulted in the worst possible outcome for 67-year-old Beryl Harman. Instead of being taken to the hospital the day her husband dialed 911, she died in her home in rural Colorado.

Dispatch audio obtained by Denver7 Investigates reveals Beryl and her husband, Daniel, both wanted her to go to the hospital, but documents from the South Park Ambulance District point to a medical refusal.

Now, Beryl's family, as well as veteran paramedics, are questioning the decisions made by paramedics on the scene that day. Denver7 Investigates uncovered how hidden documents, her oxygen levels, and her ability to refuse care all play a role in the story of what happened the day Beryl was left behind.

“I think questions being asked on this call definitely need to be asked,” said Hartsel Fire Chief Brian Cook. Cook responded to the second call from Beryl’s husband after she passed away. At that time, Cook was a volunteer firefighter and had not yet been promoted to chief.

Denver7 Investigates took insiders’ questions about what happened on the call to the Chief of Paramedics Kevin Borns. Borns was not chief at the time of Beryl’s emergency response, but Denver7 Investigates has confirmed he was the supervisor on duty during the incident.

“I would tell this story as, this is a very unfortunate incident," Borns said. “People should take away that there's two sides to every story."

One of those sides questions why a report, a documented account of what happened at Beryl’s home the day she died, sat for months in the bottom of a box inside a firehouse in Hartsel.

“When we hide reports, we hide documents. It makes us look bad,” Cook said.

Cook found the document after taking over as chief of the fire department, and started looking into the issue. He told Denver7 Investigates he believes it was intentionally placed there, out of sight, by the previous chief.

Patient death leads to questions about emergency care at South Park Ambulance District

In part, the report Cook uncovered reads, “She wanted to go to the hospital. Her husband also wanted her to go and the paramedic on scene told her that she wouldn't get into the ER any faster... if they even accepted her.”

Denver7 Investigates took the fire report to Borns, who responded with his side of the story.

“When a patient has the decision-making ability to refuse, that they have the decision-making capacity, we are not allowed to force people to go to the hospital,” Borns said.

But two veteran paramedics, both former employees of the South Park Ambulance District, point to Beryl’s decision-making capacity as a point of contention. Both paramedics asked Denver7 Investigates to disguise their identities and will be referred to as Paramedic One and Paramedic Two.

“If the crew recognized that her oxygen levels were at 50% or 60% and they did nothing, they walked away and left her, they had to have known she was going to die,” Paramedic One said.

“This patient should have been transported to the hospital,” Paramedic Two said.

Both paramedics said medical documents from the day paramedics were called to Beryl’s home highlight why she couldn’t have consented to a refusal. They said monitor readings of her oxygen levels were seriously low, preventing her from making an informed decision to decline emergency care.

South Park Ambulance District

Denver7 Investigates

Patient's death raises questions about South Park Ambulance District response

Tony Kovaleski

“Based on the physical findings that are documented within this paperwork here: The paramedic, if they are doing their job, they should try and do everything in their power to convince the patient to go to the hospital,” said Paramedic Two.

When questioned if the lead paramedic on this call did anything wrong, Borns said the response was in line with protocol. He also told Denver7 Investigates the paramedic was never disciplined for this call, to his knowledge. Borns did, however, point to lessons learned.

“I would not say there was not reason for discipline. However there would be a reason for education, spend some time and maybe go through the call again,” Borns said. “I would say lessons to be learned is good documentation.”

Borns also added that the call could have been handled better.

“We always learn from our mistakes. Nobody in this job is perfect.”

Since taking over as Chief, Borns told Denver7 Investigates he has added a more robust quality assurance program which includes more scrutiny on calls.

Denver7 Investigates reached out to the paramedics on this call, who did not respond for comment. Since the call, he has left the South Park Ambulance District for a paramedic position elsewhere.

The state's Department of Public Health and Environment also recently announced it has launched a new investigation into Beryl’s call for help.

Editor's note on Oct. 11, 2023: A broadcast version of this story mentioned the month that Beryl passed away as being November, but the event occurred in October. The story will be modified to reflect the correct month.


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