Retired Navy Chief Engineman Shon Hollis entered Naval Hospital Jacksonville, Florida, on July 8, 2014, for what he thought would be routine diagnostic procedures — a colonoscopy and an endoscopy.

His wife Christine says the couple had planned to go shopping afterward, and they giggled together as her husband of 19 years was wheeled off to the operating room, joking about his indiscreet hospital gown.

It was the last laugh they would share.

"That was the last time I saw my husband in control of his own body," a tearful Christine Hollis said.

Today, her 47-year-old husband lies in a nursing home in a vegetative state, the result of brain damage from oxygen deprivation suffered during the procedures. He can't walk, talk, eat or communicate.

While any medical procedure under anesthesia carries risk. Hollis had been diagnosed in 2008 with obstructive sleep apnea, a condition that requires anesthesiologists to take special precautions to reduce the possibility of complications.

But a lawsuit filed July 21 in U.S. District Court in Florida, claims that the physicians performing Hollis's colonoscopy were unaware of his condition — even though he'd been diagnosed with apnea at Naval Hospital Jacksonville and was monitored for it by physicians there.

The suit claims that the anesthesiologist, Navy Cmdr. John Weatherwax — mistakenly referred to in the suit as John Weathermax — failed to take the proper precautions, such as protecting Hollis's airway, which caused his oxygen levels to drop and sent him into cardiac arrest.

The suit also claims that procedures used to revive him, CPR and 'rapid sequence intubation,' which calls for inserting a tube into his airway, took longer than it should have, depriving Hollis's brain of oxygen for 22 minutes.

The family's attorney, Sean Cronin, said the entire process should have taken just three minutes.

"Due to a tragic series of medical errors and negligence ... Hollis sustained a severe brain injury as a result of a lack of oxygen while he was under direct doctors' supervision," Cronin said.

In a pre-op questionnaire, Hollis listed his medical conditions as asthma and arthritis but did not indicate he had any other breathing disorders, such as shortness of breath or difficulty breathing. The space for "other medical problems" was left blank.

Cronin said the questionnaire, drafted in 2004, is out of date and should include questions on apnea and daily use of a positive airway pressure machine, the treatment for apnea.

But he also said even a cursory look at Hollis's electronic medical record by any member of the staff may have preserved his life, since it includes the results of the sailor's sleep study.

"Incredibly, the health care team was unaware of his condition. No one on the health care team bothered to read his record," Cronin said.

Hospital spokeswoman Tami Begasse said hospital officials cannot discuss specifics of the incident, citing privacy laws, and it is against policy to comment on pending litigation.

She added, however, that the hospital remains "deeply committed to providing the best possible care to patients."

"We have an aggressive patient safety initiative ... and follow national accepted standards of care. In many cases we meet and exceed those standards," Begasse said.

The 2014 Military Health System review found that 17 military hospitals failed to meet national standards for surgical complications. But Naval Hospital Jacksonville was not among them.

In a 2014 investigative story on military medical facilities by the The New York Times, Naval Hospital Jacksonville was listed as having an acceptable rate of surgical complications.

"Not only do we continue to be on the forefront of patient safety today ... the National Surgical Quality Improvement standards characterized two surgical measurement areas — surgical site infections and blood clot standards — as exemplary," Begasse said, speaking of a program that monitors hospital surgery standards

The hospital is one of only 20 military medical facilities that voluntarily participates in NSQIP.

Still, Naval Hospital Jacksonville's patient safety history is checkered; it was the target of at least 26 malpractice suits, including 15 wrongful death lawsuits, in the early to mid-2000s.

But Cronin, who represented plaintiffs in many of those cases, said Tuesday it had been years since he was involved in a similar suit.

Navy Judge Advocate General spokeswoman Jennifer Zeldis said there have been 13 alleged medical malpractice incidents at Naval Hospital Jacksonville in the past five years that resulted in claims. They include:

**2010: Five medical malpractice incidents — two settlements, one court dismissal, two denied with no suit filed.

**2011: Three medical malpractice incidents — one settlement, one court dismissal, one denied with no suit filed.

**2012: One medical malpractice incident, now in litigation.

**2013: One medical malpractice incident, now in litigation.

**2014: Three medical malpractice incidents — one pending administrative adjudication, one in litigation, one denied.

**2015: No medical malpractice incidents other than the Hollis case.

Zeldis said the hospital has paid $605,037.80 for the three settlements since 2010.

Christine Hollis said in a press conference on the lawsuit that the couple was looking forward to life with an empty nest. They have three children and one grandchild.

Now, she has quit her job to be at her husband's side daily in the long-term care facility.

Cronin said the lawsuit was filed in part to ensure that Christine Hollis has the funds to support her husband in long-term care, which is partially covered by Medicaid.

The suit does not cite the amount that the Hollises are seeking for that support.

Cronin said he finds it shameful that the financial aspect of Hollis's care has been turned over to Medicaid.

"This isn't about me bashing the Navy. This is about the Navy stepping up to take care of its patients, doing the right thing and preventing this from happening in the future," he said.

The U.S. government has 60 days to respond to the suit.

About Patricia Kime

Patricia Kime is a senior writer covering military and veterans health care, medicine and personnel issues.

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