The family wanted someone to see Tammy daily, too. Her wound dressing required changing four times a day, but Luann--the only one skilled in treating her daughter--couldn't get home during a three-hour period in the middle of the day. And no one else in the family was available during those hours.

But Luann soon learned that without a specific order from a physician, CIGNA would allow daily nursing visits only to terminally ill patients.

CIGNA would authorize only two visits a week. A patient-care coordinator says CIGNA made repeated attempts to reach Mayfield on his way out of the country to determine the level of care Tammy needed. Mayfield denies that. He says he always wore a beeper, and his nurse kept normal office hours.

Luann ultimately hired a family friend, a nurse, to look after Tammy at midday. But he wasn't qualified to provide the postoperative care she needed.

Not only were nursing visits not frequent enough, but Betty Boesen, a registered nurse assigned to the Gentry family, admitted she had virtually no information on Tammy or her condition. She didn't know of Tammy's high risk for a deep-wound infection. She didn't know of the pus discovered at the hospital.

When Boesen visited the Gentrys' north Phoenix home on Thursday, September 8, 1988--a day after Tammy left the hospital--only Tammy's grandmother was there to greet the nurse. Boesen checked Tammy's vital signs, noting a temperature of 99.6.

She did not check the wound. She says Tammy's grandmother, who was watching Tammy when Boesen arrived, told her not to check it because Luann had recently changed the dressing.

But Luann says that's unlikely. "This was not her first surgery," she says. "We're not going to say, 'Don't touch my daughter.'"

Boesen, though, had little way of knowing what to do. On a form she later filled out after seeing Tammy, Boesen complained that there was "no discharge plan . . . no written orders for care."

So Boesen began to figure out Tammy's needs on her own. She called a CIGNA doctor at the hospital, but the doctor didn't know enough about Tammy to make an assessment. She tried to call F. Gerald Figgs, Tammy's primary doctor, but he was gone until Monday, September 12. She later noted that it was "difficult to find [a] CIGNA M.D. to take responsibility."

On Saturday, September 10, the drainage from Tammy's wound was now cloudy. Tammy's diarrhea was starting again, and Tammy had no appetite. Her temperature was still high. Luann called Figgs' nurse, who told her to watch Tammy closely.

By Monday, Tammy had begun to break out in cold sweats; her temperature had risen to 103 degrees over the weekend. More ominously, the pus coming out of her wound, which soaked the bandages, had thickened and begun to smell. And the pus now had a green tint.

The infection that would take Tammy's life had apparently set in. But it would be days before Tammy would go back to the hospital.

Luann called Mayfield's office; his nurse told her to call Figgs, because it would be difficult to get an authorization. Figgs told Luann to bring Tammy over right away.

Figgs, a pediatrician, was by no means an expert in assessing a patient who had just had major spinal surgery; in fact, he had never treated a patient in the stage of recovery Tammy was in.

Even so, his nurse did not document a complete history of Tammy's symptoms, such as how long the drainage had taken place or how long Tammy had a fever. Figgs says he wasn't aware of that crucial information, even though Luann insists she told him. Even Figgs admitted he should have asked those questions himself.

Figgs, considered a primary care doctor, didn't think Tammy needed to go back to the hospital. He didn't refer her to a specialist, such as an orthopedic surgeon, to make that decision.

Instead, Figgs prescribed Augmentin, an antibiotic Tammy had taken previously. He figured Tammy had some sort of infection, so he took cultures of her urine and the wound, noting that it was "oozing."

Then he sent her home.
Both Mayfield's nurse and CIGNA's home nurse Boesen would look at Tammy at different times that week. Luann even said she offered to pay out of her pocket to see Dr. William Li, the physician covering for Mayfield while he was out of town. But neither nurse told Luann to do anything more than call if there was a drastic change in Tammy's condition.

Boesen and Figgs talked Monday, but Boesen didn't communicate any of Tammy's symptoms to Figgs. In that conversation, they tried to determine how often a nurse could see Tammy. Boesen says Figgs told her that he would authorize only two visits a week. Figgs says he let Boesen make the decision.

For Tammy, it didn't matter who made the decision. She continued to get worse.
Luann remembers calling CIGNA six times over the next few days to find out the results of her daughter's cultures. She learned nothing.

The lab had completed a culture by Tuesday, the day after Figgs ordered it. But the results didn't make it back to Figgs' office until Thursday.

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