Looking for guidance on next steps and whether this warrants consulting a medical malpractice or wrongful death attorney.
Background
My father was a disabled veteran in his 60s with a complex medical history including a spinal cord injury (caused by a surgical error approximately 30 years ago), a stroke in early 2024, and multiple subsequent hospitalizations. He also had a tracheostomy. My brother and I hold durable and medical power of attorney. After a lengthy fight to get him appropriate care, he was transferred to a brain injury rehab facility in Colorado approximately 2 weeks ago. (In case relevant, he spent 18 months at this facility previously, so they should be familiar with his medical needs.)
The Incident
Within a day or two of his arrival, he suffered a cardiac event. Here is what we know, which is frustratingly little:
- Staff noted he was fine during rounds at approximately 6:45am
- By shift change (time unknown to us), he was found unresponsive with no pulse
- CPR was performed by staff
- EMS arrived and he had a pulse by that point
- He was transported to a hospital
- Physicians determined he had sustained approximately 15 minutes without oxygen to the brain
- He was diagnosed with irreversible anoxic brain injury
- He passed away 6 days later after being removed from life support
Our concern
He was a medically complex patient with a tracheostomy who, to our knowledge, had no prior history of cardiac issues. A trach patient is at heightened risk of airway compromise and requires close observation — we would expect a patient of his complexity to be on monitoring equipment with alarms. If he was properly monitored, how did he go from "fine" at 6:45am to pulseless with 15 minutes of anoxia without anyone responding? Either he was not connected to monitoring equipment, the alarms were not functioning, or the alarms were ignored. The window between last confirmed wellness check and discovery is also unclear to us — shift change at most facilities is around 7am, which could mean he was unresponsive for a significant period before being found.
The facility's response
I contacted the facility director shortly after the incident requesting information about his final moments. She acknowledged the request and said she would provide a report. I followed up the day he passed asking for a timeline. She responded a few days later saying she needed to speak with the assistant nursing director who was conducting the investigation and would be in touch. It is now May 3rd — 8 days after his death, 12 days since my first request, and 14 days since the incident at their facility — and I have heard nothing further. This is all documented in an email chain.
Additional context
This is not the first facility to fail him. At a prior VA-sponsored placement we documented: failure to notify family of a hospitalization, E. coli contamination found in his feeding tube, an untreated open wound, and a situation where I personally had to transport medication between facilities because the two could not coordinate. We have extensive written documentation of those issues including email chains with the care team.
Questions
Does the monitoring failure (if confirmed) constitute actionable negligence?
Is the facility's delay in providing the incident report a red flag, and what are our rights to obtain it and his full medical records?
Should we be filing a complaint with the state health department regardless of whether we pursue legal action?
What type of attorney should we consult — medical malpractice, elder care, or wrongful death?
Given that he was a VA-sponsored patient, does that complicate or change anything?
What should we be doing right now to preserve our ability to pursue this if we decide to?
We are in Colorado. Happy to answer any questions.