Two Milwaukee women were turned away from hospitals and died. One was having a stroke; the other had heart trouble.

John Diedrich | Milwaukee Journal Sentinel

Show Caption Hide Caption Gil Latus discusses how his wife's ambulance was diverted to a hospital that offered a lower quality of stroke care Gil Latus wanted paramedics to take his wife to St. Luke's Medical Center after she suffered a stroke. But the hospital wasn't accepting ambulance patients because it was too busy.

Gil Latus and his wife, Pat, had settled into a booth at their favorite lunch spot on a December day six years ago. They were about to order when Gil noticed something very wrong.

Pat was reaching out her hands, grasping at something that wasn’t there. She had a far-off look in her eyes.

The waitress walked up and recognized help was needed — fast. She called 911. Greenfield Fire Department paramedics arrived in minutes. They loaded Pat on a gurney and pushed her to a waiting ambulance.

That’s when the waiting began.

Gil told the paramedics his wife should go to Aurora St. Luke’s Medical Center. Her doctors were there, plus Gil knew it was the best care for heart attacks and strokes on Milwaukee’s south side. Everyone knew that.

Gil also knew that when it comes to treating a stroke, minutes matter.

But the paramedics hesitated. It was clear, they said, the 74-year-old was having a major stroke, but they didn’t know if they could take her to St. Luke’s.

Dispatchers had told them St. Luke’s might not be accepting ambulance patients because it was too busy. Paramedics had to wait for a callback.

A hospital turning away an ambulance with a seriously sick person? Wait for a callback? Gil couldn’t believe what he was hearing.

Don’t ambulances automatically take patients to the closest, best hospital for whatever they are experiencing?

As the minutes ticked by, Gil kept glancing at his wife, who was in the ambulance, alone and looking back at him frightened.

“I remember, ‘Let’s get going. What’s the holdup?’ ” Gil said in an interview. “It just seemed too leisurely — very, very slow. (The paramedic) was calling around and then he’s waiting for callback and it just seemed to go on and on.”

The paramedics finally had their answer: St. Luke’s was closed.

They had to take Pat to Aurora West Allis Medical Center, about the same distance as St. Luke’s, but a hospital that offered a lower quality of stroke care. They were on the scene for 14 minutes before they took off for the hospital, paramedic records show. Gil trailed them in his car.

Pat's case proved to be too much for the West Allis hospital. After nearly an hour there, with no meaningful stroke treatment provided, doctors decided she needed to be sent to St. Luke’s.

An hour and 20 minutes were already gone. By now, Pat Latus had lost consciousness and it was a race to save her life.

RELATED: Oversight of the dangerous practice of ambulance diversion in Illinois is deeply flawed

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RELATED: We found 21 deaths nationwide after hospitals turned ambulances away, but no one is tracking them

TURNED AWAY: Read the investigation

A hidden problem

Eight months later, in August 2014, a similar set of circumstances unfolded near Froedtert Hospital in Wauwatosa. Tiffany Tate suffered a stroke while working in the cafeteria at the neighboring Medical College of Wisconsin. She was turned away from Froedtert and its top-tier stroke center because the hospital was closed to ambulances for 17 hours that day, a Milwaukee Journal Sentinel investigation found.

Tate, 37, was taken instead to Aurora’s West Allis hospital, where the case was too much. She was then transferred to St. Luke’s where she slipped into a coma and eventually died. Experts said there is no way to know if Tate could have been saved, but she would have had a better chance going straight to Froedtert.

No federal agency tracks when hospitals close their doors to ambulances, a practice known as ambulance diversion. No agency investigates when such delays lead to the death or serious disability of patients.

What's more, many states and cities do not collect any information on diversions — and when they do, the information is often incomplete or barred from public release.

Paramedics know a diversion took place, but not what happens to the patients once they are back on the road. Meanwhile, patients — or surviving family members — may not even realize care was delayed.

In short, it's impossible to know how many people are affected each year when ambulances are blocked from taking patients to the closest, best-equipped hospital.

Through its own research, the Milwaukee Journal Sentinel has identified at least 21 deaths nationwide since 1990 — a number that likely vastly underestimates the total given how common diversions are and the risks that experts have identified in the practice.

Lawrence Quintana, 46, had a stroke in Las Vegas, New Mexico, and wound up at a hospital 70 miles away. Nicholas Carlson, a 5-year-old boy from Columbus, Ohio, was in cardiac arrest when a hospital turned him away.

In Milwaukee, 64-year-old Ruth Hawthorne had trouble breathing, but was not taken to the hospital a mile away.

Other cases involved gunshot wounds, stroke and asthma attacks.

Taken together, the cases provide a new window on what can go wrong when hospitals shut their emergency room doors to ambulances.

For instance, the Latus case shows the confusion — and delays — that can happen when paramedics are left wondering whether a hospital is open or closed to them. As they try to find out, crucial time slips away, and even then the destination may not be the best for the patient.

Three years ago, all hospitals in Milwaukee County voluntarily agreed to end ambulance diversion under the direction of the county’s emergency medical services director.

So far the agreement is holding, though there is no law to enforce it. Hospitals elsewhere in Wisconsin still divert ambulances and the practice continues in a majority of the nation’s largest cities.

Studies have found that overcrowding in emergency rooms is not caused by how many patients are coming in, but rather because of inefficiencies and other bottlenecks elsewhere in the hospital — with admissions and discharges, for instance.

The places that have ended diversion did so not by adding more beds but by improving operations in the rest of the hospital.

Pat Latus’ family members never knew that ambulance diversion was a policy that frequently occurred until reading about Tiffany Tate’s case.

Latus' daughter, Laurie, who works as a nurse, said her mother may not have survived, given the seriousness of the stroke — but Laurie worries similar situations could happen in places that still allow diversion.

“You just like to feel that a person has a right to the best possible care and dignity,” she said. “And I just really feel like that it didn’t happen. No matter what the outcome, she should have had the best possible care.”

'Come and help me'

It was a hot day in Milwaukee in the summer of 2012 and Ruth Hawthorne was not feeling well. She called 911, complaining of shortness of breath and feeling dizzy.

Hawthorne, a 64-year-old grandmother, was in a downstairs duplex unit that had no air-conditioning. When she spoke to her daughter, Gin, earlier in the day, she hadn’t complained of it being hot, but temperatures later soared to 100, with a heat index of 109.

On a recording of the 911 call provided to the Journal Sentinel by the family, Ruth sounds heavily winded, gasping as if she had just run a race.

“Wow. … Come and help me, please. I’m faint,” Ruth says in a pained voice.

“Are you there by yourself?” the dispatcher says.

“Yes,” she responds. “My front door is open.”

“Ok, I have people coming your way right now.”

Apparently, the paramedics didn’t get the message about the front door being open.

They arrived shortly before 2 p.m. and went to the rear door, then the side door. Both were locked. They asked the police to break down a door. As officers were about to do so, they realized the front door was open — just as Ruth had told the dispatcher.

It took them five minutes to get to her after they arrived.

They found her lying on a bed. Her blood pressure was low. She was suffering from an irregular heartbeat — something doctors had diagnosed a couple of weeks earlier.

Once the paramedics had Ruth in the ambulance, they learned Wheaton Franciscan St. Joseph’s, a mile away, was closed to ambulances.

They also were turned away by a second hospital — Milwaukee Fire Department records do not indicate which one. Froedtert Hospital, a top hospital for heart attack and stroke care, about five miles to the west, was the next closest.

Paramedics finally settled on going to Columbia St. Mary’s Hospital, about six miles away.

Ruth was in St. Mary’s emergency room about 15 minutes when she lost consciousness, according to medical records. They were able to revive her but she lost consciousness again and later died.

St. Joseph's and St. Mary's are now part of Ascension Wisconsin. A spokeswoman said she could not comment on the case because hospital leadership has changed in the years since Hawthorne's death.

Gin, Hawthorne's daughter, wonders what might have happened if care had been delivered more quickly. After the five-minute delay getting into the house, more time passed as paramedics tried to figure out what hospital they should go to.

“Why would you divert when someone’s life is on the line?” she asked.

Few moments apart

Gil and Pat Latus were married in 1959 and 54 years later, with both retired, they were constant companions.

They went to festivals, shopped together, took trips to Door County. They often ate lunch at Meyer's Restaurant on 76th Street and West Forest Home Avenue, where Gil always got the usual: enchilada omelet, wheat toast and a fruit cup.

“We were just glued together,” Gil Latus, 81, said. “Very few moments that we were apart.”

Gil had worked as a mechanical engineer; Pat was an administrative assistant in the insurance business.

Pat took care of her parents, nurtured her granddaughters who have disabilities and volunteered as a grief counselor.

“She just could get along with people,” Gil said. “She was just like a magnet. People were just drawn to her.”

Both had health issues, including stents to improve blood circulation. Pat Latus was often in severe pain because of a narrowing of her spine. She also had nagging, powerful headaches. In late 2013, her doctor suggested an epidural shot for the pain.

She was reluctant but Gil encouraged her. They would need to take her off her blood thinner to get the shot. The doctor said there was a risk of stroke, but it was very slight.

As she waited for the shot, Pat was scared.

“I remember she was laying on the gurney and said ‘I don’t want it, I don’t want it. I just don’t feel comfortable,’ ” Gil said. “The nurse said, ‘It’s nothing. We only see difficulty in one in 1,000.’ ”

The day after the shot, Pat seemed to be doing well. The two ran some errands that morning: a stop at the grocery store and a candy store to get chocolate for Christmas.

Gil suggested lunch at Meyer's.

Pat wasn’t hungry but said she would get a salad. He would get the usual. Before they could place their order, the stroke hit Pat.

As Gil raced to West Allis hospital, he frantically called his daughter and son to tell them what had happened.

He burst into the emergency room waiting area and rushed to his wife’s side.

The doctors at West Allis wanted to give her the clot-busting drug known as tPA, but were concerned that she had an epidural shot the day before, according to Pat’s medical records, which the Journal Sentinel reviewed with the family’s consent.

After 40 minutes, the doctors at West Allis concluded Pat could not get tPA there because of the seriousness of her stroke and because she had had the epidural.

She needed to go to Luke’s, they said. Another ambulance was called.

Pat’s eyes were closed, but she was still conscious, Gil said.

“She just squeezed my hand,” he said. “She was still squeezing my hand. And they just pulled the gurney away from me and that was it.”

Gil raced down Oklahoma Avenue to get to St. Luke’s, which was almost five miles away.

By the time the ambulance got to St. Luke’s, Pat was unconscious. Doctors tried an advanced clot retrieval procedure in which a catheter is threaded through the patient's artery to remove the blockage. It didn’t work. The family said their goodbyes.

Aurora officials would not answer specific questions from the Journal Sentinel about the Latus case. A spokesman issued the following statement: “Our hearts and prayers go out to this family. Our top priority has always been and will always be to provide the safest and highest quality care to the patients, families and communities we serve.”

Greenfield Fire Chief Jon Cohn didn’t return calls to the Journal Sentinel to answer questions about the case, which started there.

In an earlier interview, Cohn recounted the frustration and hang-ups that occurred when ambulance diversion was happening in Milwaukee County.

“It would be, ‘Is St. Luke’s open?’ ‘No, closed.’ ‘What about West Allis?’ ‘Closed.’ ‘And Froedtert?’ ‘Closed.’ Then it was like, ‘Can you just tell us who is open?’ ” Cohn said.

He added the end of diversion is "a good thing. It is getting patients to the right locale and quickly.”

Questions linger

Gil said it still bothers him how much time they spent waiting to see if they could go to St. Luke’s.

“I just feel that if they would have immediately taken her to St. Luke's, that would have been the proper thing to do,” he said. “It would have been the quickest and the results might have been better.

“They always should be able to take you to the closest hospital that can treat you no matter what.”

There has never been a thought of suing the hospital or paramedics, family members said. They just want answers to what happened

On Valentine’s Day 2014, two months after Pat died, Gil announced he wanted to go to Meyer's for lunch.

He’s been back regularly since then, but he has not gotten close to the booth when they were the day of the stroke.

There isn’t a day that Gil doesn’t miss Pat. He’ll be laying in bed, and say, “Did you hear about …”

“And there is nobody there,” he said. “That's the terrible part.”

Contact John Diedrich at (414) 224-2408 or jdiedrich@journalsentinel.com. Follow him on Twitter at @john_diedrich, Instagram at @john_diedrich, LinkedIn or Facebook.

John Diedrich is an investigative reporter whose work has revealed injustices and wrongdoing including hospital policies that turn away ambulances, federal agents whose flawed undercover gun-buying stings took advantage of those with mental disabilities, and fight officials who failed to protect an amateur kickboxer who died in his first bout. Diedrich, who joined the Milwaukee Journal Sentinel staff in 2004, has been recognized with numerous national journalism honors, including a George Polk Award and a National Headliner Award for public service journalism. He is a Milwaukee native and graduate of the University of Wisconsin-Milwaukee.



Email him at is an investigative reporter whose work has revealed injustices and wrongdoing including hospital policies that turn away ambulances, federal agents whose flawed undercover gun-buying stings took advantage of those with mental disabilities, and fight officials who failed to protect an amateur kickboxer who died in his first bout. Diedrich, who joined the Milwaukee Journal Sentinel staff in 2004, has been recognized with numerous national journalism honors, including a George Polk Award and a National Headliner Award for public service journalism. He is a Milwaukee native and graduate of the University of Wisconsin-Milwaukee.Email him at jdiedrich@journalsentinel.com ; follow him on Twitter: @John_Diedrich