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Lloyd Monserratt – Young Political Leader from California

Lloyd died due to surgical errors ultimately dying of severe sepsis. His Kaiser surgeon was addicted to drugs with a long arrest record. Link to the

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Lloyd MonserrattThere are no words to describe how one survives losing Lloyd Monserratt.  Lloyd believed in community empowerment and social change.  His devotion to me, our family, and to a community has been what has driven me to continue to testify before legislative hearings, challenge the California Medical Board to fulfill its mission to protect the public, and to make a legislative change that will save someone else’s life.  It is the reason why I joined the members of the KPRC to work to provide information that just might save your life.
The sad truth is that Lloyd did not have to die.  He walked into a Kaiser Permanente hospital for elective surgery and died three days later.  He was 36 years old. 
A young political leader dies suddenly and unexpectedly in a Los Angeles hospital with no cause given for his death.  When word leaks of his death, over 70 people file into the ICU ward of the hospital while media outlets contact the congressional members that he consulted for and helped.  The City of Los Angeles holds a special session during the Los Angeles City Council meeting adjourning in his memory and passing a motion to dedicate a Los Angeles City library in his memory.  His family is left in shock unable to accept that the 36 year old is gone and just Lloyd Monserrattwant to know what happened to him in that Los Angeles hospital.  Is this normal?  Should a young man’s unexplained death be left a mystery?  Lloyd was the well respected “good guy” political and community leader who was known for his dedication to a community, to our family, and to a cause.  In contrast, Lloyd’s surgeon had a drug problem and a penchant for prostitution. 

Lloyd was a Latino Vote Director for the , , and a Chief of Staff for the .  During the 3 days that Lloyd was in the hospital, I was never told that Lloyd’s condition was deteriorating.  In fact, Lloyd’s surgeon told me that his operation was a success.  This could not have been further from the truth.  Hours before Lloyd died, another physician entered his room and I asked him if Lloyd was progressing normally and he said that “he was progressing normally and that he was exactly where he should be.”  Upon review of Lloyd’s medical records, it clearly showed that Lloyd was in organ failure.  The reality was that Lloyd was on his death bed and Lloyd’s physician nor a nurse nor anyone in that hospital felt the need to tell me or Lloyd that there were complications from the surgery, that he was in organ failure, or that he was facing death.  The same physician who told me that Lloyd was “exactly where he should be” was the doctor who was left to tell me that Lloyd had died. 

With no one able or willing to provide me with a cause for Lloyd’s death, I hired a pathologist and had a private autopsy conducted.  I also contacted the executive office of the LA County Coroner and requested that they follow-up on my private autopsy and confirm or deny the results.  I am armed with two autopsy reports.  The pathologist stated that surgical errors were committed.  Left untreated, infection set in and he died of advanced peritonitis or sepsis.  I had the coroner change his death certificate from natural causes to accidental death.  I wanted the truth but I was not prepared for it.  Lloyd’s physician admitted to coming to the hospital to see Lloyd a few hours before he died.  He claimed that Lloyd was able to talk so he thought that he was okay and left.  He abandoned his patient in the last hours of his life.  Again, upon review of the medical record and his vitals, there is no way that any physician could possibly say that Lloyd was okay.

Sometime during the first round of the legal battle, I came to understand that Lloyd’s physician had an arrest record.  Unknown to me, Lloyd’s physician had been arrested 3 times in a 10 year period all while holding a license to practice medicine in California.  One such arrest was for felony possession of crack cocaine.  Lloyd’s doctor had a known felon in his vehicle that had just been released from prison days before.  When pulled over by the local police, they found crack cocaine and drug paraphernalia in the doctor’s vehicle.  When one is arrested in California, the arresting department sends a notice to all relative licensing boards.  The was notified of Lloyd’s doctor’s drug arrest and his other two arrests for solicitation of prostitution.  Yet, the medical board did nothing.  Lloyd’s doctor was never convicted for the crime upon completion of diversion.  This is an example of a “self-enroll” for the state’s former diversion program.  The doctor is given the opportunity to avoid a conviction for his crime and avoid discipline while participating in a program that his/her patients are not allowed to know about. 

Always the worrier, I checked the medical board website.  The website did not show any disciplinary actions and did not reveal any criminal issues.  The state regulates its doctor’s licenses and I felt that the website could be trusted.  As it turns out, there were other victims of this doctor.  Six months after Lloyd died, a judgment was listed for a person who had a foreign object left inside his body and suffered from months of infection.  A month after Lloyd died, a minor child was hurt by this same doctor.  There are other victims as well. 

I have testified before the State Senate opposing legislation to bring back the former confidential diversion program.  I have shared Lloyd’s story there and it made an impact then.  Former State Senator Mark Ridley-Thomas (who knew Lloyd since his days as a Los Angeles City Councilmember) chose to audit all of the other licensing boards and through SB 1441 called for the creation of the Substance Abuse Coordination Committee.  The Substance Abuse Coordination Committee is currently drafting uniform standards for the discipline of doctors, nurses, and all licensed professionals.  This was a small victory for California consumers.  Now, the California Medical Association (CMA) has come back for the third round of an extended battle.  Their legislation, AB 526, will take steps to bring back the confidential physician diversion program run by a non-profit of their choosing and will create a separate committee to create rules for discipline of doctors separate from all of the other licensing professionals.  Our elected officials have just voted to create uniform standards.  Now, they are voting for physicians to have a separate committee and make their own rules. 

We are socialized to believe that a physician will provide you the care that you need.  We have this blind faith that a hospital is a safe haven.  This was not the case.  Lloyd had a right to know his true condition while in the hospital.  He deserved to be given the care that he needed.  Lloyd was a problem solver.  He should have had the right to know that errors were committed during his surgery and be given the option to find the care he needed to save his life.  Early in his career, Lloyd worked for SEIU Local 660 organizing nurses out of Los Angeles County USC Medical Center in Boyle Heights, California.  Lloyd was so committed to changing people’s lives through the political system throughout the State of California.  Yet, tragically, the State of California failed Lloyd.
Written by Michele Monserratt-Ramos
Kaiser Permanente Reform Committee (KPRC) Public Relations Director

The following video was created by the The Safe Patient Project