TAMPA — During his recovery from cancer surgery, doctors put Jim Szamlewski on oxygen to help keep him alive.
But they discharged him from the James A. Haley VA Medical Center without the thing most essential to his survival: oxygen.
For up to six agonizing hours on Sept. 5, the 75-year-old Army veteran struggled for breath as his condition deteriorated, his wife said. The oxygen finally arrived. But Szamlewski's heart stopped 12 hours after his discharge. Though it was restarted, his brain had been irreparably damaged.
Szamlewski, of Land O'Lakes, died with the removal of life support on Sept. 9.
His is the third case detailed by the St. Petersburg Times in recent months in which a veteran died after either being misdiagnosed or discharged without vital supplies or equipment.
After a Times inquiry, the Department of Veterans Affairs regional director requested a review of the Szamlewski case by the agency's independent watchdog, the Office of Medical Inspector.
Officials at Haley, one of the nation's busiest veterans hospitals, declined to comment on Friday outside of a brief statement. They have steadfastly maintained care at Haley is excellent.
"It just don't seem right," said Szamlewski's widow, Marie. "I just don't understand why they didn't give it to him. Maybe my story can help somebody else to know they've got to stay on the VA every minute."
Saying that Haley valued transparency, hospital doctors and administrators apologized on Friday during a meeting with the widow — a meeting Haley frantically scheduled after the Times asked about the case.
The hospital also noted, Marie Szamlewski said, that Haley failed to send her husband home with a separate device to suction saliva from his mouth or throat.
Haley would not make anyone at the hospital available for an interview, including Dr. Edward Cutolo, hospital chief of staff, who met with Szamlewski (pronounced ZAM-LEW-SKI) and her daughter on Friday.
Calling the case a "serious and tragic circumstance," Haley said in a one-paragraph statement that it had conducted an internal review "to take any action necessary to prevent further occurrences of this nature."
Neither in the statement nor, according to Szamlewski's wife, during the meeting did Haley acknowledge that it was responsible for the death.
Jim Szamlewski was a retired carpenter with a wide circle of friends who liked to hunt and fish. He was a veteran who, his wife said, never had any complaint with the care the VA provided.
A smoker and drinker, Szamlewski suffered serious health problems as he aged. Part of his lung was removed because of cancer. On Aug. 28, Haley doctors removed his larynx due to cancer.
Doctors never said he was terminal, his wife said, though she said he was clearly very sick.
When Marie Szamlewski visited her husband of 34 years on Sept. 5, she was surprised to be told he was being discharged.
Marie Szamlewski, 73, said she had yet to be given lessons in her husband's care, from administering drugs to cleaning his throat wound.
She walked out to her car to get her husband's clothes. As she returned, she was surprised to see a nurse had taken her husband, wearing just pajamas, outside in a wheelchair.
Szamlewski said she saw a bottle with her husband and assumed it was his oxygen. But when she got him home, she discovered it was just a water bottle.
"He could have died in the car ride," Marie Szamlewski said.
Notes taken by a nurse who visited the home confirm the absence of oxygen and Jim Szamlewski's "extremely apprehensive" state.
About the time they got home, a private company hired by the VA called to say it was on the way with the oxygen. It arrived about 7 p.m., or six hours after the hospital discharge.
A little after 1 a.m., Szamlewski's heart stopped beating. Paramedics revived Szamlewski, but it was too late.
"They just dropped the ball," said Elizabeth Messer, 53, of Dade City, Marie's daughter from a first marriage.
The family said the VA apologized profusely, but only after the newspaper began asking about the case.
Days after the death, a VA worker called and asked Marie if the agency could have done anything differently in her husband's treatment.
"I told him they should have given my husband oxygen when he went home," Szamlewski said.
The VA employee, she said, hung up on her.
William R. Levesque can be reached at firstname.lastname@example.org or at (813) 269-5306.