The Gentrys have photo albums full of pictures of their daughter Tammy. In many of the photos, smiling, cute-as-can-be Tammy wears across her upper body a ribbon with the words "March of Dimes." Her tiny legs barely dangle over the seat of her wheelchair.

Tammy was 8 years old when she became a poster child for the March of Dimes. She had spina bifida, a birth disorder that left her with no feeling in her lower body and an abnormal curve in her spine.

Despite her disorder, she had normal mental capacities and was always full of energy.

When she reached 13, though, that changed. That's when Tammy underwent surgery to straighten her spine.

Of the 40 surgeries Tammy had endured, the one in August 1988 was the most intense. Fortunately, she had a top pediatric orthopedic surgeon to perform the operation: Phoenix physician Jack Mayfield. One of a handful of surgeons in the Valley capable of performing the operation, Mayfield had successfully treated 20 other patients similar to Tammy.

This time was no different. The two-step procedure took 20 hours and left Tammy with an incision from the bottom of her neck to the bottom of her back. The surgery was a success.

But for Tammy, the problems began after she left the operating room at Phoenix Children's Hospital and ended with her death two months later.

During that time, Tammy's parents claim in a lawsuit, Mayfield, Phoenix Children's Hospital and the medical staff of CIGNA provided "substandard medical care that clearly violated reasonable practice." They filed the wrongful-death suit against half a dozen individuals and institutions involved in Tammy's care--not because they sought to sue everyone they could, but because they believed so many people contributed to Tammy's death.

The Gentrys accuse Mayfield of discharging Tammy from the hospital on his way out of the country even though she showed ominous signs of a potentially lethal deep-wound infection. They accuse Mayfield of not providing an adequate follow-up plan in case Tammy's infection became severe.

They charge the hospital's nursing staff couldn't keep Tammy's surgical incision free of feces and urine. Because Tammy had no feeling in the lower part of her body, that problem was particularly hard to control. But her mother, a friend and even Mayfield say they complained repeatedly to nurses that the helpless girl was forced to lie in her own excrement.

They charge that CIGNA doctors responsible for Tammy's care after she left the hospital didn't discover Tammy's fatal infection until it was too late. Nor, they contend, would the insurer approve frequent enough visits by a nurse to check on Tammy. And when Tammy, showing signs of a deep-wound infection, visited a CIGNA staff doctor, instead of sending her back to the hospital or referring her to a specialist, the doctor sent her home with an antibiotic that proved ineffective.

The charges speak to some of the problems that face healthcare today, from overworked nurses to insurance companies that, some charge, put the bottom line before patients' health.

The case also points up possible problems in the growing popularity of health maintenance organizations, as more and more companies seek lower-cost group health plans. Critics say that HMOs such as CIGNA bend over backward to make sure their medical staffs keep costs down, running the risk of sacrificing patient health.

"The care and treatment CIGNA provided to Tammy graphically illustrate that financial considerations compromised CIGNA's care and treatment of Tammy from the very beginning," the Gentrys' attorney, Ray Slomski, charges in a court document.

But in interviews, legal documents and court proceedings, all the parties named as defendants in the Gentrys' lawsuit hotly deny wrongdoing, although some admit mistakes were made.

Mayfield says Tammy showed symptoms only of a minor problem--her skin wasn't healing--when he decided to send her home. Mayfield's attorney says the Gentrys knew the high risks of the surgery, and how hard it was to prevent infection in a patient such as Tammy.

Hospital nurses testified that because of her incontinence, it was almost impossible to keep Tammy completely clean from excrement. An expert witness for the hospital challenged whether Tammy's infection was actually caused by exposure to her own excrement, as her parents say, or was brought on by bacteria already in her body and skin.

In court depositions, CIGNA workers say that in treating Tammy, they did not fall below the standard of care specified. They also say that the family prevented some care.

Other CIGNA officials refused to comment, saying corporate policy prohibited them from discussing cases that have been in litigation--even though the case is now closed.

"Tammy Gentry's care and treatment were not in any way influenced by financial concerns," CIGNA did say in a court document.

But in a field where workers regularly shy away from criticizing colleagues, the amount of finger-pointing in Tammy's case is remarkable.

Mayfield, for example, testified that he chided nurses for not keeping Tammy's wound clean. The nurses, however, deny under oath that Mayfield said anything to them. A CIGNA document indicates that CIGNA tried to contact Mayfield immediately after Tammy's discharge from the hospital. Mayfield denies that.

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