Kate Miner walked into the Indian Health Service hospital, seeking help for a cough that wouldn’t quit.
An X-ray taken of Ms. Miner’s lungs that day, Oct. 19, 2016, found signs of cancer.
What exactly the IHS doctor said to Ms. Miner about her exam remains in dispute. Notations in her medical file indicate the doctor told her to come back for a lung scan the next day. Her family says they never were given such instructions and weren’t told of the two masses the X-ray revealed.
What is clear is that no further tests were done. And no IHS provider followed up when Ms. Miner returned twice more to the hospital, the only one on the Cheyenne River Reservation, over the next six months, medical records show.
Finally, on May 7, 2017, as the 67-year-old Ms. Miner lay crumpled on a hospital cot, the right side of her body shaking, a physician assistant ordered a CT scan, after her family insisted, according to the records and family members.
“You have two very large masses in your right lung. It’s probably a malignancy,” Ms. Miner’s daughter Kali Tree Top recalled the physician assistant saying.
Ms. Miner reached for her daughter’s hand and started to cry.
Ms. Miner’s encounters with the IHS, and her family’s repeated efforts to get her help there, illustrate how the federal agency can fail the patients who need it most.
At the Cheyenne River Health Center in Eagle Butte, a succession of IHS medical providers treated Ms. Miner’s symptoms but never followed up on initial concerns about her condition, making each visit effectively her first, medical records show. Operational problems such as mismanaged patient chart systems affected her care, those records show. When hospital staffers discovered serious health problems, the results weren’t clearly communicated to Ms. Miner or other providers to ensure the right testing was done, according to the medical records and her family.
“The sad thing is, our people don’t have a choice. That’s all that is there,” said Harold Frazier, the Cheyenne River Sioux tribal chairman.
In recent years, tribal leaders, health experts and federal regulators have identified widespread problems with the IHS. Ms. Miner, like many of the agency’s patients, was let down by the care she got there, not because of one catastrophic medical mistake, but by a cascade of shortcomings that the agency has failed to fix despite years of promises from its leaders.
IHS hospitals, including the one in Eagle Butte, have been cited by regulators time and again over the past decade for dangerous medical care, including haphazard record-keeping, negligent follow-ups and sending home patients who turned out to be critically ill.
In October, Ms. Tree Top sued the government over her mother’s care, alleging that the IHS never informed Ms. Miner of how sick she was and failed to treat her illness.
The IHS declined to comment on Ms. Miner’s case because of the pending litigation. In a court filing Friday, lawyers for the Justice Department denied the allegations. In a written statement, Charles Fischer, the Eagle Butte hospital’s top official, said the facility has a “sound medical records and records management program” and had improved the consistency of its care in recent years.
The IHS provides free health care for 2.6 million Native Americans under treaties between the U.S. government and tribes. The agency is supposed to help a patient population often in desperate need of medical attention, with high rates of chronic illnesses and deaths related to substance abuse. On much of the Cheyenne River Reservation, life expectancy is 67.6 years, according to data from a University of Wisconsin research group, more than 10 years less than the U.S. average and lower than in North Korea.
The Wall Street Journal reviewed hundreds of pages of medical records provided by the IHS to Ms. Tree Top about her mother’s case. They describe Ms. Miner’s multiple visits to the Eagle Butte facility in 2016 and 2017.
Kate Miner’s family wasn’t used to seeing her feeble and helpless. She stood 4-foot-11 and weighed barely 120 pounds, but her knack for small talk and storytelling, her sharp tongue and her spectacles gave her an air of authority.
She grew up in one of the tiny Cheyenne River communities scattered across this isolated reservation roughly the size of Connecticut, learning to run cattle as a little girl from her rancher father. She dropped out of high school, working construction and other jobs before becoming a nurse at the IHS hospital and then a detox coordinator.
She raised three daughters and a son by herself in Eagle Butte—at about 1,300, the largest town on the reservation.
Ms. Miner knew most everyone in Eagle Butte, friends said. After retiring in 2002, she would wake at 5 a.m. and drive around town to see what was happening before heading home to entertain visitors over cigarettes and coffee.
In the fall of 2016, Ms. Tree Top noticed her mother had a bad coughing bout while returning from shopping for groceries at Walmart in Pierre.
Ms. Miner had smoked for many years before cutting down, and she had interstitial lung disease, which causes lung scarring. She also suffered from scleroderma, a painful rheumatic disease affecting the skin. She occasionally saw non-IHS specialists in Rapid City, 170 miles away. She hadn’t visited a pulmonologist there in over a year, but more recently had seen a cardiologist who ordered tests on her heart. Ms. Tree Top worried the cough was bronchitis contracted from one of Ms. Miner’s great-grandchildren. She made an appointment for her mom at the IHS.
For her own care, Ms. Tree Top tried to avoid the IHS. As a girl, she had to get her broken arm reset at a Pierre hospital after an IHS doctor hadn’t set it properly, leaving her in pain, she said.
With no other nearby options for her mother, Ms. Tree Top took Ms. Miner to the Eagle Butte hospital, which opened in 2012 to replace a 1950s-era facility one-third its size.
A nurse checked Ms. Miner’s vital signs but couldn’t do a throat culture because the hospital had run out of the long cotton swabs used to do them, records said.
Saira Khan examined Ms. Miner and ordered an X-ray. A radiologist noted a “pleural-based mass” in the right lung—meaning a likely cancerous tumor—and a second mass in the same lung, records show. The radiologist suspected a “neoplasm,” an indication the second tumor was also likely cancerous, and recommended a CT scan.
According to Dr. Khan’s medical notes, she shared the X-ray results with Ms. Miner.
Ms. Tree Top said Dr. Khan didn’t mention any masses or tumor to them. She said Dr. Khan reported some “cloudiness” in her mother’s lungs that could be causing the cough and wanted a closer look.
It was getting late in the day. “Would it be all right, if we need to, could we call you back in?” Ms. Tree Top recalled Dr. Khan saying about scheduling the scan.
Dr. Khan sent Ms. Miner home with a prescription for cough syrup and antibiotics, records show.
Ms. Tree Top remembered her mother elbowing her as they left the hospital, saying: “See? I told you all they were going to do was give me antibiotics and cough syrup.”
“Well, at least it’s nothing serious,” Ms. Tree Top replied.
Dr. Khan’s medical notes indicate she thought she had been more explicit with her patient that day. “Would order a CT, patient will come to get CT tomorrow. Patient verbalizes understanding and agrees with the plan,” her notes say. Further down in her notes, Dr. Khan wrote, ambiguously: “Follow up in months.”
Dr. Khan didn’t speak with Ms. Miner or her family again, family members said. According to Ms. Tree Top, nobody from IHS ever contacted them about needing Ms. Miner back for a lung scan.
Dr. Khan, who left the IHS in August, didn’t respond to requests for comment.
The confusing records, and the seeming lack of follow-up, wasn’t a new problem at the Eagle Butte facility. The hospital was cited in at least nine reports between 2005 and 2009 by the Centers for Medicare and Medicaid Services, the U.S. hospital regulator, for failing to properly document patient information, for poor follow-up and unsafe care. (In the years that followed, its inspections were conducted by the Joint Commission, a health-care nonprofit that accredits hospitals. Its reports are confidential.)
Mr. Fischer, the hospital’s top official, said all employees must undergo annual training on records management, and that any allegations of problems are “seriously and swiftly addressed.”
Cindi Pochop, one of the doctors who treated Ms. Miner, said patients’ records at Eagle Butte are sometimes mislabeled, often disorganized and difficult to locate quickly. She said there is no clear system to ensure that providers view important findings, and serious problems can get missed. She declined to comment on Ms. Miner’s case because of the litigation, and said the agency had been trying to address the issues, with minimal success.
As recently as October, a Department of Health and Human Services report found the IHS’s record-keeping systems continued to cause problems, saying the transferring of patient information was “burdensome, error-prone, and time-consuming.”
Over Christmas 2016, as family gathered at Ms. Miner’s home, her daughters noticed she ate less. Ms. Miner smiled at the police scanner Ms. Tree Top bought her so she could trail the emergency vehicles around the reservation the way she liked. She soon retreated to her room, saying she was exhausted.
Several days later, she called Ms. Tree Top.
“Kali, my girl, I’m not feeling well,” she said, explaining she was nauseated, with body cramps.
On Dec. 30, Ms. Miner returned to the IHS hospital. A nurse checked her vital signs, and her Oct. 19 visit was referenced for comparison, records show.
Mr. Fischer said if a patient doesn’t show up for a CT scan, “the order remains outstanding in the system until the patient contacts the department.”
In Ms. Miner’s chart from that day, which included her medical history, the staff didn’t list any outstanding orders for a CT scan, nor was there any reference to the X-ray results showing tumors.
A physician assistant examined Ms. Miner, wrote her a painkiller prescription and sent her home an hour after she arrived, the records show.
Over the next several months, Ms. Miner grew more fatigued and withdrawn. In early spring, she contracted what seemed like a stomach bug. When she didn’t get better, Ms. Tree Top and her brother, John, took their mother to the hospital on April 7.
That day, Ms. Miner vomited six times, medical records show. She had lost nearly 14 pounds since her last visit and was now down to 87 pounds. The physician assistant who examined her, Martin Katambwa, described her as “well-nourished,” records show.
Mr. Katambwa was the third different provider Ms. Miner saw in three visits—meaning he, like the others, had little familiarity with her or her family’s medical history. IHS facilities long have been hampered by high staff turnover and a lack of continuity of care. In 2017, the Eagle Butte hospital had a vacancy rate for doctors of 50%. It now stands at 27%.
Neither Mr. Katambwa nor the nurses who saw Ms. Miner mentioned in her charts that day the masses found months earlier. It isn’t clear whether they ever saw them in Ms. Miner’s records.
Mr. Katambwa diagnosed her with gastroenteritis and sent her home with anti-nausea medication.
A few days later, Ms. Tree Top gave her mom a hug.
“You’re just a sack of bones,” she said.
“I’ll still kick your ass,” her mother shot back.
By May, Ms. Miner was in near-constant pain, family members said. One morning, she cried out to her son that her right side was hurting and shaking. Panicked, John called Ms. Tree Top and his other sister, Lisa, telling them to meet him at the IHS emergency room.
During that visit the two masses in Ms. Miner’s lungs were spotted again—on a new X-ray and the CT scan her family requested. She was seen again by Mr. Katambwa, who consented to the scan despite misgivings that it wasn’t necessary, according to the family.
The tests allowed Mr. Katambwa to assess her ailment in her medical records as “right lung cancer.” He told Ms. Miner she needed to return the next day for outside referrals, the family said.
Mr. Katambwa didn’t respond to requests for comment.
Back home, the family gathered around the table. Ms. Miner began speaking in Lakota, which her own parents had spoken to her when she was little. Aside from a few terms of endearment, her children had never heard her speak the language before. Her daughters strained to recognize words they understood. It sounded like their mom was talking about a dream she’d had where Lakota spirits visited her and told her the tumors wanted to take her.
Four hours later, Ms. Miner’s pain had grown excruciating. She wanted to return to the IHS hospital.
There, Ms. Miner reported a pain level of 8 out of 10, a nurse documented.
Robert Martin Jr., the physician who saw her that night, wrote in her chart that Ms. Miner had come to the emergency room earlier that day and was “found to have a right lung mass which is probably Cancer.”
Ms. Miner’s daughters said Dr. Martin never physically examined her, instead popping his head into the exam room, saying she was very sick and needed to come back tomorrow for referrals. They said Dr. Martin had a nurse give Ms. Miner antipain and antinausea medication before discharging her.
Dr. Martin said in an interview he didn’t recall Ms. Miner’s case, but that he always examined his patients.
In 2015, Dr. Martin’s medical license in Arkansas was suspended, then restricted, after he allegedly prescribed painkillers to two patients with whom he was sexually involved, according to that state’s medical board. The women were prostitutes at a Nevada brothel, board records show, and appeared on the HBO show “Cat House: The Series.” Dr. Martin also allegedly prescribed steroids to himself, the records show.
As part of the sanctions, he offered to practice only on Indian reservations or at Department of Veterans Affairs hospitals, Arkansas medical-board records show. Eight months after his suspension, the disciplinary order was dismissed, and the restrictions were lifted.
In an interview, Dr. Martin denied all the allegations, saying he was seeking to rescue the women from prostitution and was targeted by their pimp. He no longer works at the IHS. He provided the Journal with a 2018 letter from his IHS supervisor praising his work at Eagle Butte.
The next morning, Ms. Miner and her daughters returned to the IHS hospital to get cancer-specialist referrals.
Dr. Pochop, the doctor who treated Ms. Miner that day, spoke with her about getting an outside oncology appointment, writing in her chart that Ms. Miner’s treatment options were now likely limited because of chronic health problems and frailty.
She referenced in her notes the CT scan that Dr. Khan originally recommended after an “abnormal” X-ray the prior October. “Unfortunately, pt did not return the next day as directed,” Dr. Pochop wrote.
Dr. Pochop wanted to know why Ms. Miner didn’t return for the CT scan, her daughters said.
“She never told us to come back,” Ms. Tree Top told Dr. Pochop. Had they known about the masses in October, they would have rushed to get whatever treatment their mom needed, she said she told the doctor.
Ms. Miner, distraught about her diagnosis, just stared at the floor.
An oncologist who reviewed Ms. Miner’s charts at the Journal’s request said she likely was very sick already when the first X-ray caught the two masses seven months earlier, and that it was doubtful any treatment would have cured her.
Nevertheless, said Kathryn Locatell, a forensic geriatrician who specializes in examining medical records and also reviewed the charts, Ms. Miner should have been given the opportunity to seek treatment earlier—and to put her affairs in order, given that she was gravely ill.
Over the next several days, Ms. Tree Top said, she unsuccessfully tried to get specialist appointments for her mother at Regional Health Rapid City Hospital through IHS’s referral department. The IHS staff didn’t complete the correct paperwork, and it took more than a week for the agency to send out the proper forms, she said.
On May 24, less than three weeks after the diagnosis, Ms. Miner’s daughters drove her to the Rapid City hospital, where doctors told her she had small cell lung cancer. It had spread to her liver and brain. She died there six days later.