Armstrong's two sons have accused a hospital of causing grave heart complications

The sons hired a heart specialist at the University of Pennsylvania to review the medical record

Armstrong's family settled in September 2014 for $6 million

CINCINNATI – When Neil Armstrong died Aug. 25, 2012, at a Cincinnati hospital, his family simply attributed the cause to complications from coronary bypass surgery. A month later, the first man to walk on the moon was buried at sea with military honors and the thanks of a grateful nation.

Armstrong’s family has never talked publicly about the astronaut’s last days in Mercy Health Fairfield Hospital, largely to stay in harmony with how he lived. The modest, humble man from Wapakoneta, Ohio, shied from the spotlight in the decades after his flight aboard Apollo 11 and his July 1969 walk on the lunar surface.

But this week, The Cincinnati Enquirer learned that for two years after Armstrong’s death, his two sons threatened a wrongful-death suit against Mercy Health, the largest hospital system in Ohio. They accused the Fairfield hospital of causing a heart complication and triggering a series of grave medical errors.

The Armstrong sons, Rick and Mark, hired a heart specialist at the University of Pennsylvania to review the medical record of more than 5,000 pages. The doctor concluded that not only were the hospital mistakes fatal, Armstrong most likely didn’t need the bypass surgery then.

“While Neil indeed had significant coronary disease, THERE WAS NO EMERGENCY here,” Dr. Joseph Bavaria wrote in a July 1, 2014, letter with capital letters for emphasis. “Neil’s death could have been avoided had the proper standard of care been provided.”

In the weeks after, Mercy Health officials worried that the Armstrong sons would talk about their father’s treatment at Fairfield, according to documents. Ultimately, in an agreement filed with Hamilton County Probate Court in September 2014, the hospital system said it did nothing wrong but agreed to pay the Armstrong family $6 million.

In return, the family agreed to be silent about the last days of the first man on the moon.

Details about the death and turmoil

This week, The Enquirer received an unsolicited package of documents that provides voluminous detail about Armstrong’s death and the turmoil that followed. This account is based on these documents and the probate court file.

The Enquirer reached out to members of the Armstrong family and Mercy Health for comment Tuesday evening but didn't get any immediate replies. Armstrong's wife, Carol, told the New York Times: "I wasn't a part of it. I want that for the record." She told the Times that she signed off on the agreement because otherwise she would have been removed as executor.

The settlement payout was filed in probate court and is a public document. But the package sent to The Enquirer included never-before-seen papers, including the letter from Bavaria, vice chief of cardiothoracic surgery at Penn Medicine, which runs the Hospital of the University of Pennsylvania.

The package also contained emails between the lawyers in the matter and internal Mercy Health memoranda on the opinions of two outside doctors who the hospital system asked to review the record. Those doctors said the treatment did meet the standard of care, and some decisions were judgment calls.

’Golf on back burner for a while’

On Aug. 5, 2012, Armstrong turned 82. James Hansen, author of the authoritative biography “First Man: The Life of Neil A. Armstrong,” wrote in the book’s preface that Armstrong underwent the bypass surgery Aug. 6.

Hansen got an email from Armstrong on Aug. 11, which turned out to be his last to Hansen:

“I had checked into my gastro doc to check out an apparent reflux problem. It seemed an unlikely connection (for several reasons) but it turned out to be the right thing to do. We did a nuclear stress test leading to an angiogram, leading to a quad bypass. Recovery is going well but golf will be on the back burner for a while. Hope to be kicked out of the hospital in a day or two. My best, Neil.”

Blockage of a heart vessel can be treated with medication or surgery, depending on the patient’s overall condition. Armstrong chose the surgical procedure that reroutes blood around the heart.

At some point, likely after Armstrong’s Aug. 11 email to Hansen, the Fairfield heart-care team decided Armstrong needed a pacemaker to regulate his heart rhythm.

As part of the installation, temporary wires connected to the pacemaker protruded from Armstrong’s chest. Just hours later, as Armstrong recovered in a step-down unit, a nurse pulled out the wires. Bavaria pinpointed that action as triggering the cascade of complications.

“While the hospital records state that it was according to protocol, there was actually no compelling reason to pull them at that time especially with no surgeon around,” he wrote.

Making ‘THE wrong critical decision’

The pull tore the pericardium, the sac surrounding the heart, and blood filled the space, a phenomenon called a tamponade. Within 20 minutes, Armstrong was in trouble. Bavaria wrote, “The deterioration was fast.”

Another 27 minutes passed until Armstrong was taken to the cardiac catheterization lab to drain the blood from the sac. Armstrong improved a bit, then blood filled the sac again. He spent 20 minutes in the cath lab, blood pressure falling, kidneys failing. Then he was taken to the operating room.

Bavaria wrote: “There is NO STANDARD OF CARE ANYWHERE I KNOW OF where patients who are bleeding after an epicardial wire pull go to a cath lab. They ALL GO TO THE OPERATING ROOM DIRECTLY. ASAP. ANY OPERATING ROOM. This is a ‘code red or hot case.’ "

Bavaria concluded: “Going to the cath lab was THE critical wrong decision.”

An hour and 37 minutes after the epicardial wire pull, surgeons repaired the heart damage. But Armstrong’s brain had been starved of oxygen.

On Aug. 15, nine days after the bypass surgery and at least four days after the wire pull, hospital staff removed Armstrong’s breathing tube. He was not able to breathe on his own, so the tube was reinserted. “This did not help matters during a critical post anoxic brain injury phase,” Bavaria wrote.

Armstrong died 10 days later.

In December 2012, his last will and testament was filed in probate court. He left all personal effects to his wife, Carol. He willed the rights to his voice, photograph and signature to the Purdue Research Foundation at Purdue University, his alma mater.

The case of ‘Ned Anderson’

In early July 2014, internal Mercy Health memoranda presented the conclusions of two doctors the hospital system had asked to review the case. The patient’s name was camouflaged as “Ned Anderson.”

Dr. Richard Salzano, a cardiothoracic surgeon at Yale Medical School, said the bypass surgery and pacemaker were appropriate. The wire pull probably caused “a little bleeding,” but Salzano believed the major damage came in the cath lab when doctors drained blood from the heart sac.

Salzano told Mercy Health that taking “Anderson” to the cath lab first was “defensible.” When things turned dire, the cath lab doctors could have cracked his chest right there, instead of moving into the operating room. Still, “The patient would likely have recovered if the OR had been the first option.”

Dr. J. Stanley Hillis, a cardiologist at St. Vincent’s Hospital in Indianapolis, echoed Salzano. The memo said Hillis “ ‘didn’t really see anything that represented less than ideal practice,’ although he said that ‘some plaintiff’s expert’ may criticize the decision to do (the bypass) instead of treating the patient with medication for some period of time before operating.”

Seeking change at Mercy

During the investigation into a potential wrongful-death claim, Cincinnati lawyer Wendy Armstrong represented the Armstrong sons. She is married to Mark Armstrong.

On July 3, 2014, two days after receiving Bavaria’s review, Wendy Armstrong wrote to Nancy Lawson, Mercy Health’s lawyer with the Cincinnati firm Dinsmore & Shohl.

Wendy Armstrong noted that Mercy Health had a letter from the Cleveland Clinic, one of the nation’s leading heart hospitals, conveying the view that epicardial wire pulls could be dangerous: “In elderly patients, with co-morbidities, and with recent coronary artery bypass surgery, this often can lead to a fatal outcome.”

“We are confident that we would prevail should this case be decided in a legal forum,” Wendy Armstrong wrote. “If this matter becomes public, the resulting damage to your client’s reputation would come at a much greater cost than any jury verdict we can imagine. In a case such as this, we all know that the world will see and hear every detail of this case as it unfolds, not just those morsels the court deems admissible – the fact that a world hero lost his life at Mercy Fairfield will leave its mark in history.”

Wendy Armstrong asked Mercy Health for $7 million in damages. She said the Armstrong sons also wanted Mercy Health to adjust treatment of coronary patients. Her letter said:

“Create a procedural protocol so that never again will an epicardial wire be pulled when there is not a cardiothoracic surgeon and an operating room ready to receive a patient that experiences pericardial tamponade. No one should ever die in a hospital because a nonessential procedure was ordered and performed at a time when the hospital was not prepared for a known and potentially fatal complication.”

The letter asked for a speedy resolution since the Armstrong sons planned to attend festivities starting July 18 in Florida marking the 45th anniversary of the Apollo 11 mission that took their father to the moon.

Anniversary becomes a deadline

On July 8, Lawson asked Wendy Anderson. “Do Mark and Rick intend to discuss the wrongful death claim at the Kennedy Space Center if no settlement is reached by Friday July 18?”

Wendy Armstrong responded that the anniversary celebration would draw national news coverage, writing:

“Additionally, Rick and Mark have been solicited by several book writers and filmmakers for ‘information about Neil that no one already knows,’ who we know will be in attendance. Obviously, the information about this wrongful death claim would prove extremely useful to such projects, and the boys’ involvement would net a monetary gain far in excess of the demand that has been made for settlement."

But, she added, “They are more interested in a private resolution with the hospital that would serve to prevent avoidable deaths in the future. So if a settlement is reached by the 18th, there will certainly be no discussion about Neil’s death to anyone, ever.”

They reached a deal. By September 2014, lawyers for Carol Armstrong, the executor of the estate, file the settlement agreement. “Although the hospital and health care providers who provided care and treatment to Mr. Armstrong stand by their care and deny that any malpractice occurred, the hospital, on behalf of itself and the health care providers, agreed to pay a total of $6 million” to Armstrong’s two sons, sister, brother and six grandchildren.

Carol Armstrong did not receive any portion of the settlement. The law firm handling the estate, Taft Stettinius & Hollister, received $160,000 in fees and costs for handling the probate case. The settlement’s broad outlines were filed in probate court unsealed and required all the parties to keep the matter confidential.

Last year, Mercy Health merged with another Catholic hospital system from Maryland and now is known as Bon Secours Mercy Health.

This summer, the world commemorated the 50th anniversary of the Apollo 11 mission with recollections of the life of Neil Armstrong, many of them serious, some whimsical. At the Ohio State Fair, artists carved a tribute to the Ohio-born astronaut in his spacesuit saluting the U.S. flag, all out of butter.