comprehensive

Struggling to breathe, the patient stepped out of the registration line in the hospital’s overwhelmed emergency department to find help. Her chest hurt, she told the triage nurse on duty that evening at Brockton’s Good Samaritan Medical Center. The nurse, backed up with more than a dozen waiting patients, thought it was anxiety and told her to get back in line.

That is where the patient collapsed. Medical personnel rushed in and tried to jump-start her heart using a defibrillator and life-saving medications, according to a state inspection document and an internal staffing report. But it was too late.

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Two weeks after the patient’s death on Sept. 13, state health inspectors arrived at the hospital, owned by for-profit Steward Health Care, to investigate. During their review of patient records, they found an emergency department with recurring staffing problems that at times seemed to be in near-meltdown.

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