The Flomax incident

Three pills. Arnold Bravo’s family says before he took them he was relatively stable and active—his stage IV liver disease was in check, and he was well on his way to getting a new liver. But after he took the pills, he was weak, severely debilitated, and in and out of the hospital. He died just three months later at the age of 53, leaving behind two sons and three grandchildren.

The pills Bravo took were Flomax, generally prescribed to treat enlarged prostates, not liver disease. In fact, the official Flomax prescribing information—published by Boehringer Ingelheim, the drug’s manufacturer—says patients should inform their doctors of “any kidney or liver problems” before taking the drug.

The truth is, Bravo shouldn’t have taken any Flomax, because it wasn’t actually prescribed to him. Rather, the name on the label said “Arnold Bryer.” Neither Bravo nor his family noticed the name mix-up until after he’d begun taking the medication.

Just as this article readied for print, a lawsuit detailing events leading up to Bravo’s death was settled out of court with a confidentiality clause. But the family’s claim against Longs Drugs (today CVS Pharmacy) remains of interest as a cautionary tale, if nothing else.

“There are certain professions—pharmacist is one of them—where there is zero margin for error,” said the Bravo family’s Sacramento attorney Piotr Reysner before the lawsuit was settled.

The family’s complaint against CVS, filed June 10 of this year, made for particularly brutal reading. “As a direct, legal and proximate result of defendants’ negligence and reckless disregard, defendants caused and/or contributed to the death of decedent,” stated the complaint.

Rick Rodgers, the Sacramento attorney representing CVS, did not respond to two calls for comment that were made prior to the settlement. But in his July 10 response to the Bravo complaint, he wrote that the “mistaken delivery of Arnold Bryer’s prescription to Mr. Arnold Bravo … cannot by any stretch of the imagination be viewed as extreme, outrageous or egregious. If the allegation is true, it would be a regrettable error—nothing more.”

Reysner scoffed when asked about that defense at the time. “It’s a wonderful admission of liability, but someone died,” he said.

Arnold Bravo’s troubles began about 15 years before his death on August 10 of last year. That’s when he contracted hepatitis C. He didn’t seem to be too bad off until late 2007, when his liver began to fail.

In April 2008, doctors at UC Davis Medical Center told him he had stage IV liver disease. They put him on a list for a donor liver and began prescribing him a cocktail of medication—at least half a dozen of them, according to papers Reysner filed with the court. These included the antibiotic Cipro, the diuretic Lasix, a beta blocker called Propranolol, the proton-pump inhibitor Protonix and a stool softener called Enulose. Bravo was taking so many drugs that he was visiting the Natomas Longs Drugs pharmacy department three times a week, where he quickly got on a first-name basis with the pharmacy staff.

And things were apparently going well, according to Micaela Van Dine, Bravo’s stepdaughter (she’s also married to Reysner and is currently acting as the legal guardian ad litem for Bravo’s three grandchildren in the suit). Then around Mother’s Day in 2008, Bravo told Van Dine he had a new drug to take, which he didn’t name.

“This was totally common,” Van Dine said. “He would get new medications every week.”

Van Dine said Bravo took the recommended two-pill-per-day dose that Friday, and again on Saturday. But that night, Bravo called Van Dine and said the new drug, Flomax, was actually prescribed for someone else—Arnold Bryer.

Thinking that the error might just have been a misspelling of Bravo’s name, Van Dine visited Bravo Sunday morning and called UC Davis Medical Center to ask what had happened. While waiting for a response, Bravo collapsed.

Though Bravo regained consciousness when the fire department arrived, he spent the next three days in the hospital. The Bravo family lawsuit alleged the Flomax caused Bravo to go into “liver shock.” His condition was now so far gone he was off the donor liver list, and it would take considerable time before his body could recover to the point where a liver transplant was possible. Van Dine said family members also immediately transferred all Bravo’s prescription needs to another pharmacy.

What’s more, Van Dine said Bravo was only home for a week before his kidneys failed, forcing him to return to the medical center. But then his condition improved, and in mid-June, Bravo received a liver transplant. He was pretty shaky, Van Dine said, adding that Bravo would have died without the transplant.

According to Van Dine, Bravo did well for about three weeks, then complications set in from the immunosuppressants doctors had prescribed. Designed to counteract organ rejection, the drugs also left Bravo vulnerable to infection. Once again, Bravo returned to the hospital.

On August 10, he died.

“Prior to the ‘Flomax incident,’ Arnold was fairly stable, active,” Van Dine said. “He could drive. There was no urgency for a transplant. But after the incident, there was urgency. Flomax thins the blood. It says if you have liver disease, don’t take this drug.”

By the time of Bravo’s death, attempts to recover at least some money from CVS had already begun (Van Dine estimated that the Bravo family’s post-Flomax incident hospital bills totaled $66,000). On May 29, just a few weeks after Bravo first collapsed, Reysner wrote a letter to Longs Drugs’ legal counsel, explaining what had happened and asking for $500,000.

“Certainly a lawsuit of this type would not be something Longs would like to be involved with, especially given the negative publicity Longs would be forced to endure,” Reysner wrote. According to Reysner, CVS (which bought out Longs) countered with an offer of just $50,000.

In early 2009, in response to Van Dine’s request for Bravo’s medical records, CVS’ pharmacy liability claims office sent what they considered the most “relevant” of their files. But Van Dine noticed a curious omission—there was a six-week gap in the records, from the time when Bravo first left the hospital after the Flomax incident until about a month before his death. CVS eventually provided those records as well, Van Dine said, though the company insisted they weren’t relevant.

On March 16 of this year, Reysner wrote another letter to CVS, this time dropping the settlement figure to $300,000. “Please accept this letter as our final demand for settlement of this claim,” he wrote. “We still contend that negligence related to medications issued to Mr. Bravo could have lead to his death. If this final demand is not accepted, we are prepared to take this case to court.”

Reysner said CVS ignored him, so on May 25, 2009, he wrote yet another letter, this time to each member of the CVS board of directors. Now his settlement figure had risen to $400,000. And Reysner’s patience had worn thin.

“I want you to think carefully on this matter,” Reysner wrote. “I have a big mouth and I love attention. … I give you until June 12, 2009, for one person with authority to settle this case to call me. After that, this letter, prior letters, the complaint, and anything else I can think of will be sent to every news agency I can find an address for.”

There was no reply, so Reysner filed suit.

Then, about two months later, Reysner got his way. At SN&R press time, the case was settled for an unknown dollar amount. And the charge against CVS for negligence and reckless disregard in the case of Arnold Bravo went into the silent vault of settled lawsuits.