RaDonda Vaught’s Story: Her mistake and sentence detailed
Prosecutors rarely, if ever, prosecute medical professionals for medical errors. However, RaDonda Vaught, a former nurse at the prestigious Vanderbilt University Medical Center, faces 12 years in prison for a clinical mistake that caused Charlene Murphey’s death in December 2017.
Murphey checked into the hospital, seeking a diagnosis for frequent headaches and vision loss. Doctors diagnosed her with a brain bleed, which they managed to control. Before Murphey’s discharge, doctors recommended a PET scan to check for cancer.
Charlene complained of claustrophobia, so doctors instructed Vaught to give her Versed, a calming sedative. Instead, RaDonda accidentally gave Murphey vecuronium, a powerful paralyzer, which stopped her breathing and rendered her brain-dead.
Radonda Vaught was sentenced to three years probation in May 2022
Criminal Court Judge Jennifer Smith sentenced Vaught to three years probation, citing her remorse and honesty about the error as mitigating factors.
Before the sentencing, Radonda apologized to Murphey’s family as the conversation about systemic hospital failures and the dangers of criminalizing medical errors had drawn attention away from the victim. Vaught said:
“I’m sorry that this public outpouring of support for me has caused you to continue to live this over and over. No one has forgotten about your loved one, no one has forgotten about Ms. Murphey. We’re all horribly, horribly sorry for what happened.”
Some of the victim’s relatives said they didn’t want Vaught to serve time in prison as Charlene would have forgiven Radonda. However, they stated that Charlene’s husband wanted Vaught in prison.
Prosecutors weren’t opposed to probation, but they argued against judicial diversion. However, Judge Smith granted the diversion, allowing Radonda to have her charges dropped and records expunged after completing probation.
Hundreds of health workers protesting outside the courthouse expressed relief following the decision. They warned that criminalizing mistakes like Radonda’s would lead to more deaths in the long run.
“I’ll forever be haunted by my role in her untimely passing,” Vaught said. “She did not deserve that.”
Vaught administered the wrong medication after overriding the drug-dispensing system
RaDonda searched for Versed in the automatic drug dispenser but couldn’t find the drug: it was listed under the generic name midazolam. She then used an override mechanism, unlocking more medications. Vaught typed ‘VE’ as she’d done before, and the cabinet offered vecuronium.
Court documents claim that RaDonda ignored warnings that would have stopped her from administering the wrong drug.
Furthermore, Vaught didn’t realize that Versed was a liquid and vecuronium a powder that had to be mixed into liquid before administering. The cap sealing the vecuronium also has a warning sign in caps reading ‘Warning: Paralyzing Agent.’
Prosecutors point to the override as vital to the reckless homicide charge Vaught faces. RaDonda acknowledges she used an override to access the lethal drug but claims that overrides constituted standard procedure at the hospital.
During her trial before the nursing board, Vaught said that at the time of Charlene’s death, the hospital hierarchy was instructing nurses to use overrides to counter delays occasioned by an ongoing remodeling of the institution’s health records system.
Vaught said that she’d performed at least 20 overrides to provide care for Murphey. “Overriding was something we did as part of our practice every day,” Vaught said. “You couldn’t get a bag of fluids for a patient without using an override function.”
Lorie Brown and Michael Cohen, experts following the case, told npr that nurses in many hospitals often use overrides to access medication. However, Brown said that dangerous drugs like vecuronium should be inaccessible through overrides.
“This is a medication that you should never, ever, be able to override to,” Lorie Brown said. “It’s probably the most dangerous medication out there.”
Vaught opines that Vanderbilt shares some responsibility in Charlene Murphey’s death
RaDonda allegedly admitted her mistake to colleagues after discovering her blunder. She also acknowledged her mistake before the nursing board.
“I know the reason this patient is no longer here is because of me,” RaDonda said, struggling to hold back tears. “There won’t ever be a day that goes by that I don’t think about what I did.”
However, she also states that Vanderbilt shares some responsibility for Charlene’s unfortunate death. Following the incident, Vanderbilt failed to report the error to state and federal regulators.
The hospital claimed Murphey died of ‘natural’ causes, neglecting to mention vecuronium, Murphey’s death certificate reveals. Vanderbilt fired Vaught and settled with Murphey’s family, barring them from publicly discussing the death.
In October 2018, an anonymous source alerted authorities to the unreported medical error that caused Murphey’s death. Later that month, the Tennessee Department of Health decided not to pursue disciplinary action against Vaught.
Eventually, the circumstances surrounding Murphey’s death came to light. Vanderbilt offered the Centers of Medicare a ‘plan of correction’ indicating the steps it would take to prevent the recurrence of such an error.
Months after prosecutors filed criminal charges against Vaught, The Tennessee Department of Health reversed its decision not to try RaDonda without offering the reasons behind its about-turn. Sympathetic members of the board said that they had no choice but to revoke Vaught’s license. As Vaught’s vilification continued, Vanderbilt remained in the clear.
However, during a January 2019 meeting of the Tennessee Bureau of Investigation, the Nashville district attorney’s office, and the Department of Health, it became apparent that the Department of Health had concluded Vanderbilt played a significant role in the death, TBI special Agent Ramona Smith testified.
“In this case, the review led the [Department of Health] to believe that Vanderbilt Medical Center carried a heavy burden of responsibility in this matter,” Smith said.
RaDonda’s attorney, Peter Strainse, said that Vaught had been scapegoated to protect the reputation of one of Tennessee’s most prestigious hospitals:
“We are engaged in a pretty high-stakes game of musical chairs and blame-shifting. And when the music stopped abruptly, there was no chair for RaDonda Vaught. Vanderbilt University Medical Center? They found a seat.”
Nurses opined that a conviction would prove detrimental to the profession
Vaught’s case has drawn national attention due to its rarity. To nurses, however, the case carries heavy significance: it could open the door to criminal prosecutions for medical errors.
Prosecutors don’t allege that RaDonda intended to kill or hurt Murphey, or a foreign substance impaired her judgment. Vaught faces up to twelve years in prison for a medical error.
Nurses are worried because most of them use the kind of automated system Vaught used at Vanderbilt. The past two years have been exceptionally brutal on nurses, leaving them exhausted and prone to error.
Janie Harvey Garner, a St. Louis nurse, said that she once switched strong medication but spotted her error at the last minute. She said:
“You have the nurses who assume they would never make a mistake like that, and usually it’s because they don’t realize they could. And the second kind are the ones who know this could happen, any day, no matter how careful they are. This could be me. I could be RaDonda.”
Two years after RaDonda’s error, another nurse administered verapamil instead of Versed by using an override. The patient didn’t die, nor did the mistake trigger a criminal investigation.
Several nurses, including one clad in scrubs, showed up in court to support RaDonda. “This will set a precedent for anyone, anyone who deals directly with the public who if you make a mistake it could cost someone their life or serious bodily harm,” Tina Vinsant, a nurse from Knoxville, said.
“The consequences of putting the total case on to one nurse for one incident is a burden, an atlas and I feel this poor child is bearing the burden of the world and I’m here to support her,” Tanya Radic added.
Murphey’s son, Gary, said Charlene would forgive Vaught for her mistake
In February 2019, Murphey’s son, Gary, said that his mom would likely forgive Vaught for her mistake.
“I know my mom well, and she would be very upset knowing that this lady may spend some of her life in prison,” Gary said. “She probably had a family, and it’s destroyed their life too.”
Gary said that they struggled to get an answer from Vanderbilt staff regarding their mother’s condition. A doctor told the family that Murphey had been given the wrong medication or too much medication.
“She was so cheery and talking to us and the next thing you know we never got to speak to her again,” Gary said. Doctors said that Charlene would never recover and recommended taking her off the breathing machine.
“They said she was not going to get no better,” Sam Murphey, Charlene’s husband, said. “So I did it – I had to do it – I couldn’t keep her like that.”
A year later, the family found out that Vaught administered vecuronium. The fact that the drug formed part of a deadly concoction used to execute death row inmates incensed some family members:
“That’s the one thing that upsets me,” Gary said. “When I see it was a drug they use for lethal injection, I don’t know man – that’s just not right. I understand everybody makes mistakes, and I feel for the lady who is involved in this because I have a heart that takes after my mom, but it bothers us still.”
Charlene Murphey’s family has spoken little about the case due to the family’s settlement with Vanderbilt.
However, in December 2019, Charlene Murphey’s grandson Allen, a family member unconstrained by the confidentiality agreement, accused Vanderbilt of covering up Murphey’s death.
“A cover-up — that’s what it screams,” Allen said. “They didn’t want this to be known, so they didn’t let it be known.”