A civil lawsuit against Sharp Chula Vista Medical Center alleges that a doctor’s order for a patient’s immediate chest X-ray was delayed for more than 10 hours, contributing to his death from a pulmonary embolism — a major blood clot that blocked the arteries of his lungs.

While the details of the case are particular to one individual, experts say the outcome is far too common, illustrating the need for greater vigilance of, and advocacy around, a threat that kills a person every six minutes, according to the National Blood Clot Alliance.

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Medical research has found that the risk of clots forming, especially in the deep veins of the legs, increases with the length of a hospital stay. Even short periods of convalescence, from one to three days, increase the likelihood of a condition called deep venous thrombosis, which can cause clots to break loose in the extremities and travel through the bloodstream, passing through the heart and lodging in the lungs. And this elevated risk continues even after patients are discharged home, making the need for ongoing preventive measures critical.

For Andrew Gabor, this ramp of elevated risk started in Denver during a hospital stay to treat a significant infection. Medical records provided for review by his sister, Maria Healey, show that the 38-year-old man, who was working two jobs, had type 2 diabetes, which contributed to the infection, causing a difficult recovery. Determined to ease her brother’s path, Healey brought him to live with her and her family in Chula Vista, a move that allowed Gabor to continue working remotely in order to keep his health insurance.

“Being the oldest sister, I just felt that need and desire to take care of him as the youngest brother,” Healey said. “Our mom wasn’t able to do it because she has MS, and so I offered to take him home, and he agreed to it.”

It was during his convalescence that Gabor began to experience extreme back pain that seemed to be triggered by sitting wrong on the couch.

“Over the course of two or three days, he just couldn’t get comfortable, and he was brought to the point of tears because he was in so much pain, and we finally decided he needed to go to the ER,” Healey said. “He also started feeling this numbness in his leg that was driving him crazy because he couldn’t walk anymore.”

A magnetic resonance imaging (MRI) scan revealed that a very large herniated disc and narrowing of the spine were causing the back pain. Sharp Chula Vista admitted Gabor on Feb. 16, 2024, and he underwent spinal decompression and fusion surgery six days later.

Back brace in place, Gabor began physical therapy after the surgery, still spending most of his time in a hospital bed.

Ten days after the surgery, Healey said she received a call from her brother early in the evening.

“He was just really alarmed, almost in tears … he said … I’m just worried I might have had a heart attack, I’m not really sure what’s happening, maybe I’m having a panic attack or anxiety attack,” she said.

She arrived not long after to learn that her brother had experienced severe chest pain when attempting to get up to use the bathroom. His heart was racing, his breathing distressed. Required to leave by 8:30 p.m. due to the end of visiting hours, Healey said she returned the following day and was disheartened to see that her brother’s affect had considerably worsened, his skin taking on a gray pallor. He died shortly thereafter, on March 4, 2024, his death certificate later listing the main cause as a bilateral pulmonary embolism.

Healey said she had many concerns about the care her brother received during his stay, from the lack of responsiveness of some members of the nursing staff to the fact that he was not transferred to the hospital’s intensive care unit when the chest pain started. But she said she was flabbergasted when she received the results of a state investigation by the California Department of Public Health.

“The report came almost an entire year after he died and, when I got it, I was shaking as I read through the papers,” Healey said. “I just couldn’t believe what they had found, and I felt vindicated that he shouldn’t have died, that I was right that something had happened, that this shouldn’t have happened.”

A copy of the state’s investigative report, based on multiple interviews and reviews of medical records, says that a CT angiography of Gabor’s chest “was completed 12 hours after it was ordered,” a slightly more precise estimate than the lawsuit cites.

While investigators report that hospital policies do not explicitly define the meaning of the term STAT, investigators say in their write-up that a subsequent interview with an X-ray technician said that staff “knew it was supposed to be completed ‘right away.’”

An interview with a hospital physician also “stated that the expectation was for a STAT order to be completed within one hour … or there was no point (in) ordering (it to be completed) STAT.”

“I was very angry, very very upset, because, as his older sister, I felt like I was there to protect him, and I wasn’t able to do that,” Healey said. “I was told he was in the best place, that he would be given the best care possible, and it just wasn’t the truth.”

Acting on behalf of her brother and of her mother, for whom she serves as a guardian, she sued Sharp in San Diego Superior Court on July 11, alleging wrongful death, abuse, neglect and negligence. The suit, served on Sharp last week, seeks unspecified punitive and compensatory damages and reimbursement for attorney’s fees.

Sharp declined to comment on these allegations, indicating in an email that it does not comment on pending litigation.

Reading the report, and also her brother’s death certificate, sent her to the Internet looking for answers, where she found stoptheclot.org, the website of the National Blood Clot Alliance. There she learned that blood clots are estimated to kill between 100,000 and 300,000 Americans per year, which the organization says “is greater than the total number of people who lose their lives each year to AIDS, breast cancer and motor vehicle crashes combined.”

She also found that the organization had created its own acronym to help patients and their loved ones remember the signs and symptoms of imminent blood clot danger. S stands for swelling in the leg, T for tenderness and leg cramps, O for being out of breath, P for passing out, C for chest pain, L for leg discoloration, O for an overdriven heartbeat and T for time to call 911.

“He fit so many of these that it’s just outrageous,” Healey said. “I wish I had known this ahead of time, and I wish that more people knew just how dangerous and fast this can be.”

Dr. Rushad Patel, an oncologist with Beth Israel Deaconess Medical Center, a teaching hospital of Harvard University Medical School in Boston, reviewed Gabor’s death certificate and an excerpt from his medical record that outlined his condition, said that deep venous thrombosis (DVT) was likely the cause of the blood clot in the lungs.

“A patient admitted with leg pain who later develops a fatal (pulmonary embolism) was likely experiencing a DVT that then migrated to the lungs,” Patel, also a member of the clot alliance, said in an email. “If the clot is large enough, it can severely affect the function of the heart and prevent proper oxygenation of the blood, which, if severe, can be fatal.”

Preventive action, he added, is always the first order of business: “Hospitals are expected to assess every admitted patient for their risk of developing clots. For higher-risk patients, prevention can include medications, mechanical devices as well as early mobility. Medications include small doses of anticoagulants (such as heparin) to prevent clots from forming. Getting patients out of bed and walking as soon as it’s safe can keep the blood flowing and prevent clots.

For some patients who cannot move or have more limited mobility, external devices or compression stockings can help prevent clots as well. These measures, especially the use of anticoagulants, have to be balanced against bleeding risk. For example, if a patient has recently had surgery or bleeding complications, medications may not be safe, and the team will rely more on mechanical devices and mobility. The important principle is that clot prevention should always be actively considered and tailored to the individual.”

Family members, he added, should feel empowered to ask if their loved one has been assessed for blood clot risk and what steps are in place to prevent them.

“If medications are not being used, it’s reasonable to ask why — sometimes the answer is a high bleeding risk,” Patel said. “They can also look for practical signs: Are compression boots being used? Is the patient encouraged to walk or do leg exercises? Is the care team attentive to symptoms like swelling, redness, or pain in the legs?

“Most importantly, family members and patients themselves can act as advocates by making sure prevention is on the radar. Knowing one’s risk factors and asking the questions signals to the care team that clot prevention matters.”

Gabor’s medical records do indicate that he received “DVT prophylaxis” during his stay at the hospital, and Healey said she does remember him being given compression socks for his legs, though their purpose, she said, was not communicated.

“It was very unexplained what they were for,” she said. “They were these Velcro cuffs to put on, and he wasn’t told why he should use them; he was just told that they were there if he wanted to.”

She added that a risk assessment is missing.

“I don’t recall AJ ever having a risk assessment done when he was first admitted to the hospital, and I haven’t found proof that one was done,” she said.