Doctor's absence while boy was dying is subject of complaint

Updated: Oct 14

By Johnnie Rosario & Eric Rosario

johnnie@kanditnews.com & eric@kanditnews.com

Pediatrician Dr. Dennis Sarmiento, is another subject of numerous complaints made by David Lubofsky to the Guam Board of Medical Examiners in the wrongful death of his son, Asher Dean Lubofsky.


Asher Dean was only five years old, when he died at 7 a,m. on October 31, 2018 at Guam Memorial Hospital. He was admitted the day before, and his condition worsened gradually over night. According to Mr. Lubofsky's previous statements to Kandit News, his son was never admitted to the ICU despite his deteriorating condition, the nurses never set him up with a breathing tube despite his labored breathing, and a doctor never checked on him through the night.

An investigative report on Asher Dean's death by the U.S. Centers for Medicare and Medicaid Services secretly published May 3, 2019 confirmed Mr. Lubofsky's statements, and more. Asher Dean is identified in the CMMS report as Patient 6.

According to the report, three doctors - Medical Staff #14, Medical Staff #15, and Medical Staff #16 - were responsible for Asher Dean's care during his overnight stay at GMH.

The report went on to detail the notes written into Asher Dean's chart during his stay in the Emergency Room, then the Pediatrics Unit. From his admittance at 11 a.m. on October 30 to his death the next day at 7 a.m., the boy was suspected of strep throat, pneumonia, and presumptive Dengue Fever. His fever, cough, chest congestion, facial color, and oxygen level became worse with each passing hour. His breathing became more labored throughout the night.


"During an interview on 5/2/19 at 2:30pm, with medical staff #15 he validated that he was the M.D. on call and spoke to the nurse two times and gave order. Staff #15 further explained that "The last report he received was the CBG results and no further called indicating that respiratory status continued to worsen and patient no responding to treatments and medications. The nurse did not communicate the urgency of physical symptoms or else he would have come in to assess the patient or called the E.R. doctor to go and evaluate the patient. The expected plan was to come in the morning to see the patient 6"."

Mr. Lubofsky constantly asked the nurses on duty for a doctor to see his son, and for his son to be intubated so he could breathe and rest. The nurses, on the order of doctors whom they had called, gave the boy Albuterol and Tylenol for his symptoms.


Hospital policies:
"Hospital policies reviewed on 5/1/19 titled: "Rapid Response Team" revised on 1/2013 reveals that it is a team of experts clinicians that can provide effective communication with the primary physician on the patients status and work collaboratively with primary nurse clinician to continue to improve early recognition and response to changes in patient condition. The goal is the reduction of Code 72 (Code Blue activation) events through early interventions.
- Accessing vital signs "revised on 5/2018 reveals - the purpose: To provide guidelines in how to properly obtain vital signs on a pediatric patient as well as to follow the set parameters given. Assess respiratory for retractions, use of accessory muscles, nasal flaring, grunting, stridor, and pursing lips. Heart rate: bradycardia (slow) less than 80, tachycardia (fast) 140-160 in a child.

The following are successive notes on Asher Dean's chart:

10:24 PM (October 30, 2018) - Patient refusing O2 via NC, Respiratory Therapist (RT) sets up O2 mist 28% on 6 Liter (L)
11:38 PM - Chest retractions, nasal Flaring, coarse crackles (an abnormal breath sound), head of bed elevated (HOB), face mask at 6 L
11:46 PM - Temperature (Temp.) 102.8, Tylenol given per order and cooling measures implemented

Notes over the next seven hours show the boy's life was slipping away as it became more difficult for him to breathe, blood began to secrete from his nares, his rash spread, and he began hallucinating. Still, no doctor came by his bedside.

6:53 AM (October 31, 2018) - Nurse checked patient noted and he is unresponsive with faint pulses. CPR initiated and code blue called - refer to code sheet

Still, no doctor came.

7:00 AM - Pulseless patient (Pt).
7:01 AM - Pt. intubated by ER MD, advance cardiac life support (ACLS) protocol followed, primary care physician (PCP) informed, intensive care unit (ICU) nurse and nursing supervisor present during code.
7:15 AM - Patient Asystole
7:16 AM - Time of death called by ER Doctor

Mr. Lubofsky reported these events to the Guam Board of Medical Examiners, the Allied Health Board, and the Guam Board of Nurse Examiners in 2019, but to no avail. At the time, there was no public record of what happened. He eventually filed lawsuits in the Superior and District Courts of Guam for the wrongful death of his son.


Over this past summer, Mr. Lubofsky caught a break. GMH was forced to disclose the May 3, 2019 CMMS report, which implicated the nurses, respiratory therapists, and doctors in the death of Asher Dean.


Based on the report, Mr. Lubofsky renewed his hope that Guam's medical licensing boards could evaluate the newly-available evidence and help to prevent wrongful deaths like Asher Dean's from happening again.

He filed the following complaint against Dr. Dennis Sarmiento, the primary physician assigned to Asher Dean, and a pediatrician:


"October 30/31,2018, ASHER DEAN Lubofsky was hospitalized at Guam Memorial Hospital. Dr. Sarmiento was the assigned Primary Physician. Dr Sarmiento never, not once came into my sons’ room to monitor or check him at any time, nor not all night, even though he received messages from nurses that Asher’s condition was getting much worse. I was told by nurses that Asher needed to get into ICU, but as no doctor came to check him, he was never admitted. Asher passed the next morning at 715am on the 31 follow protocol at the hospital, nor did he provide proper standard of care for a dying child in the Pedia unit.
"Children who require intermediate- or higher-level care need a high-level health care professional who is in-house and readily available to respond to the patient immediately should the child’s condition deteriorate. Dr Sarmiento should have known that Asher’s condition was deteriorating as he was the primary doctor assigned and nurses were sending him messages. He also had labs that were very high. Treating Pedia patients from home is not in line with a standard of care for a child who is dying and who was not stable. Interestingly, 5 minutes after Asher passed away, Dr Sarmiento ran into Ashers room. Where was he all night? He was contacted at least twice regarding failing condition of Asher, but did not come in to assess Asher nor do any follow up. IF he had gotten into the hospital or did what is appropriate as outlined above that would be appropriate standard of care. To sit at home or wherever waiting for calls from nurses does not meet standard of proper care with a child who has labs off the chart and who require intermediate- or higher-level care. Waiting for nurses or blaming nurses for the death of a patient is very inappropriate even with failings in the systems ,Why didn’t Sarmiento put Asher into the Pedia ICU? The unit was not busy that night."
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