A physician in Ohio ordered fatal doses of painkillers 28 times, to 28 different patients. Nobody stopped him. Now the physician has been fired and his license suspended, and a slew of other medical professionals have been removed from patient care while the hospital completes its investigation — but many people are asking how this ever happened in the first place.

Why didn’t someone notice?

All of the patients involved in this story were hospitalized at Mount Carmel West, a major hospital in Columbus, Ohio, between 2015 and 2018. All of them were in intensive care. Some of them were terminal. Some of them, like a 44-year-old man who wasn’t in extremely ill health before he developed trouble breathing, seem like they should have survived their trip to the hospital. All of them received doses of fentanyl, a powerful painkiller, well in excess of normal amounts — which led to their deaths.

Currently, at least six wrongful death lawsuits have been filed regarding the patients — and more are likely to follow. The real mystery, however, is not what happened in this hospital, but how it happened. Everyone seems to agree that there are checks and balances in place that should have prevented even one overly-large dose going out — let alone a few dozen of them.

Normally, when a doctor orders a drug, the prescription is reviewed by a pharmacist — who has the power to stop the prescription from going out. It’s then dispensed by an automated machine that should send warning signals that a dose is too high. The nurse who administers the drug also has the ability to prevent the drug from getting to the patient.

Internal records should have also raised a red flag once patient charts were reviewed. While errors can happen somewhere along the way, the sheer number of errors that took place indicates that the entire system was broken — or that one charismatic doctor was somehow able to overcome it.

If you suspect medical malpractice in the death of your loved one, it’s important to ask questions. The truth of what happened to your loved one is out there but it may take some effort to uncover.