Virginia Personal Injury Lawyer Blog

This is the first of a series of postings about Virginia Tech President Charles Steger's explanations why he issued no warning to the Virginia Tech campus the morning of April 16, 2007 - a warning that two students had been shot, one fatally and one mortally, at West Ambler Johnston ("WAJ") residence hall.

The postings come from the trial record and exhibits and are offered in response to numerous inquiries we have received about our recent jury verdict, one holding the university negligent for failing to warn and holding the university accountable for the subsequent deaths of 30 students and faculty on the campus at Virginia Tech.

The shooter shot the first two students around 7:12 a.m. in a WAJ dorm room and the next 30 in second floor classrooms of Norris Hall two and one-half hours later. University President Charles Steger, who had the authority to warn the campus that a gunman was on the loose following the first two shootings, elected to sit mute and issue no warning until the later shootings broke out.

Why?

His reasons have been diffuse, contradictory, and occasionally untrue.

He didn't come to these positions alone. By last count, Virginia Tech has spent approximately $1 million following the shootings to contract with public relations agencies to help "shape the message" - a message designed to deflect attention away the consequences of the greatest failure of leadership in college and university history.

After the first two shootings, President Steger had his staff notify the Governor that "We have one dead, one wounded, gunman on the loose," but he elected to keep those facts secret from the campus community.

Later that morning, 30 more students and faculty were killed and over 20 others wounded. When the consequences of his failure to warn struck him, he embarked on a campaign to rewrite the history of that morning and put his decisions, or absence of them, in the best possible light under the circumstances. He enlisted Larry Hincker, the head of university public relations, and together they formulated a plan which they launched at the 7:40 p.m. press conference the night of the shootings.

Through this posting and a series of postings which follow, we will array for you their disquieting efforts to create an alternate version of the truth, a parallel universe in which they successfully, at least for awhile, persuaded the public and the university's Board of Visitors that they had done their "absolute best" after the first two shootings.

In this posting, subtitled "The Press Conference," you will get a flavor how, in a public relations crazed university, facts get massaged into what we call "destination truths," "truths" which have little truth associated with them, but which are sufficiently plausible to be marketed as true despite their inaccuracy.

The police were on the scene by 7:24. a.m. In dorm room 4040 at West Ambler Johnston residence hall lay two bodies, a young woman still alive, but barely, suffering a bullet wound to the top and back of her head. Her body was near the window. Lying up against the inside of the dorm room door was a male student who had been shot in the face. Before dying he had bled profusely. On the floor were two spent 9 mm shell casings, indicating the probable weapon was a semi-automatic pistol. Thirteen bloody footprints exhibiting an approximately size 10 sneaker tread headed up the hall and ended at a stairwell. On the door handle to the stairwell was a bloody thumbprint.

A Policy Group, consisting of President Steger and other administration members, was assembled to decide what and when to tell the campus of the shootings. They knew time was limited.The press, which monitored police calls, were expected to call at any time. Members of the Policy Group started to draft an alert: "Two students have been shot in West Ambler Johnston, one fatally and one has been taken to Montgomery Regional Hospital. No gun was found at the scene. Police are searching for the shooter," but this alert was never given - at least to the campus.

Shortly after the Policy Group had been convened, President Steger directed that the Governor be notified. His Chief of Staff was told: "We have one dead, one wounded, gunman on the loose." Sometime later each member of the Board of Visitors was advised: "Two students were shot this morning, one fatally."

However, when the group decided what to tell the campus, all references to a homicide and a wounding were deleted, as was a reference to there being gunman, armed and dangerous, on the loose, Instead, the campus was simply told by email that: "A shooting incident occurred at West Ambler Johnston earlier this morning. Police are on the scene and are investigating."

A link to a copy of the email follows:

Ex. 32 - Email sent 9-26 about shooting incident.pdf

At 9:42 a.m., gunshots were heard at Norris Hall, and by 9:50 a.m., the next fifty students and faculty had fallen, victims of the same shooter as the first two shot.

Eight months earlier, on August 21, 2006, an escaped prisoner who had already killed to non-students off campus was seen approaching campus or was on its periphery. Under the guidance of Kurt Krause, Vice-President of Business Affairs, the university promptly issued a warning of his sighting, and he was captured later that day just off campus without further injury, death, or incident.

On April 2, 2007, after a note was received about a bomb threat at Torgersen Hall, the building was promptly evacuated, the campus was notified of the threat and advised to stay away from the building, the area was cordoned off, and traffic re-routed. While the police concluded the threat was undoubtedly a hoax, safety dictated a "real threat" response.

On April 13, 2007, a bomb threat made against three buildings by the same note writer, a note that recited the bombs were set to go off "this coming weekend," evoked an identical response. Clearly a hoax, it had to be taken seriously. The consequences of an error in judgment were unacceptable.

As the media descended on the campus on April 16th in response to the worst massacre in the history of public education, the dominant question asked: "Was their any warning issued after the first two shootings?" A press conference was called for 7:40 p.m. That was going to be one of the earliest questions asked.

Shortly after 6:00 p.m., President Steger and Larry Hincker discussed how they were going to handle this question at the press conference. A plan was agreed upon. President Steger would read a prepared statement, then the floor would be turned over to Chief Flinchum to take questions. Flinchum had not been at the Policy Group meeting, so he wasn't privy to what the campus had been told. Steger would read his prepared statement then step aside.

Larry Hincker prepared a first draft of a statement for President Steger to read to the assembled press. While he later denied having composed the timeline of events Mr. Steger would read into the record, it was composed on his laptop and sent as an email from his laptop to his desktop, where it could be printed in multiple copies for the press corp and distributed as President Steger's statement. His denial of authorship wasn't very convincing. Nor was the text of the statement upon later review at trial.

A copy of the email with the timeline can be found at the following link. Note the 7:30 a.m. entry about a person of interest and the 9:26 a.m. entry stating that they warned of a homicide.

Ex. 39 - Email Hincker sent with timeline.pdf

A link to the video of President Steger's press conference can be found here, which is posted on our Facebook page. Note how the entire press conference follows the fictitious timeline created by Mr. Hincker.

http://www.facebook.com/video/video.php?v=155483654580878&saved

The timeline and press statement contained two major untruths, misstatements the press corps treated as true because they had no alternative. It was the only basis they had for their story.

Having advised the campus of no details about the "shooting incident" at West Ambler Johnston in the 9:26 a.m. blast email, no mention that there had been a homicide, or
a mortal wounding, or a gunman on the loose, presumably armed with a semi-automatic pistol, the Steger statement read verbatim at the press conference recited that at 9:26 a.m., "Virginia Tech community - all faculty and students - were notified by e-mail of the homicide investigation and scene at West Ambler Johnston Residence Hall."

The Steger statement answered the question on everyone's mind. Had a warning been issued after the first two shootings? Of course! The campus was notified of the homicide at WAJ and the scene there was described! That statement, obviously, wasn't true.

But Hincker and Steger didn't stop there. The press conference opening statement also asserted that as early as 7:30 a.m., the police had a person of interest whom they were pursuing. This, too, was a fabrication - at least as of 7:30 a.m. There was no person of interest until 8:30 a.m., when the boyfriend of the young woman who had been shot in WAJ was identified, and he wasn't identified until then because the female shooting victim's identity wasn't known until after 8:15 a.m., when her roommate returned from a weekend away.

A lookout for him was issued between 8:30 and 8:40 a.m., and at 9:24 a.m., he was pulled over in a traffic stop. Everything pointed towards his non-involvement. He wasn't fleeing the Tech campus, he was headed back towards it. His buddy had called to say his girlfriend had been shot. She wasn't answering her cell phone. At the traffic stop he was polite and cooperative but distressed and crying. He needed to find her. At 9:30 a.m., the police called the Policy Group to advise them: "We have him, but it's unlikely he's the shooter."

When the shooting broke out at Norris Hall, the police wished him good luck with his girlfriend, handed him his car keys, and drove off to the new crime scene. This did not deter President Steger, however, from repeating with near monotony susequently that one of the reasons they didn't warn the campus earlier was that they had a "suspect in custody who was being interrogated when the second shootings broke out."

There will be subsequent postings dedicated exclusively to the fictions that Steger and Hincker created around this "person of interest," as they sought to morph him at first into a "suspect' and then into the "perpetrator" as their needs arose. These contentions also evaporated under the glare of trial preparation.

Despite their falsity, the 7:30 a.m. non-existent "person of interest" and the 9:26 a.m. blast email, which Steger and Hincker claimed advised the campus of the homicide and scene at WAJ, took on independent lives of their own. More to follow.

Hospital staff still fail to report most patient harm

Thirteen years after the Institute of Medicine took health care providers to task in its seminal report To Err is Human for underreporting medical errors, hospital personnel still do not report most incidents in which patients are harmed as a result of medical care. This was the finding of a new U.S. Department of Health and Human Services Office of the Inspector General (OIG) investigation.

The investigation looked at 189 hospitals where Medicare patients discharged in October 2008 experienced 293 unique adverse events, such as medication errors, surgery errors, falls, and hospital-acquired infections. Federal investigators found that hospital staff failed to report the events 86 percent of the time, despite internal incident reporting systems meant to improve patient safety by preventing recurrences.

The OIG report comes after a study last year which found that methods commonly used to detect adverse events in U.S. hospitals missed 90 percent of the events. In that study of three hospitals, just 1 percent of adverse events were captured by the hospitals' voluntary reporting systems.

Hospital administrators admitted that "underreporting can affect patient safety efforts by potentially skewing resources toward prevention of more easily identifiable occurrences that happen at a point in time (such as patient falls) rather than complex events that occur over a longer period and are more difficult to detect (such as blood clots)," the OIG report said.

However, hospital administrators told investigators that staff often may be confused about what constitutes harm and what needs to be reported.

Hospitals must track adverse patient events as a condition of their participation in the Medicare program, and the vast majority of U.S. hospitals do. However, federal regulations and accrediting agencies' requirements are silent as to how hospitals should identify and analyze the events; it is left to individual hospitals to determine which adverse events to monitor. Investigators found that among a subsample of 34 hospitals, none maintained a list of events that staff are required to report.

The hospital administrators interviewed for the OIG report said personnel likely did not perceive 62 percent of the unreported events as reportable, while 25 percent of the unreported events were those that staff would normally report but didn't.

In an earlier blog entry we discussed the risk of Tylenol for pediatric use. Tylenol can be liver toxic to adults, too, in excess doses.

"Well, I'll just be careful how much Tylenol I take!"

The chemical name for Tylenol is acetaminophen, and it is in numerous medications by that name. If you were to search the label of the following medications, you'd see no suggestion that the drug contained Tylenol,and if you were to take anyone of these medications AND Tylenol you might be putting yourself at risk. There are at least fifty drugs which contain acetaminophen but don't have Tylenol in the name.

Do any of these drugs sound familiar to you? They all contain acetaminophen:

• Excedrin Tension Headache,


• Excedrin Quick Tab


• Midol Maximum Strength Menstrual,


• Coricidin HBP Maximum Strength Flu,


• Vicks Formula 44 Custom Care Cough & Cold PM,


• Triaminic Multi-Symptom Fever,


• Alka-Seltzer Plus Cold,


• Coricidin D,


• Sinulin,


• Alumadrine,


• Chlor-Trimeton Sinus


• Maxiflu CD,


• Maxiflu CDX


• Hexaflu


• Triaminic Cough & Sore Throat,


• Children's Triacting,


• Drixoral Cough/Sore Throat,


• NyQuil,


• Nyquil Cold Medicine,


• NyQuil Multi-Symptom, All-Nite Cold


• Robitussin Cold Cough and Flu,


• Duraflu,


• Maxiflu DM,


• Comtrex Non Drowsy Liquigel


• Vicks Dayquil Daytime Cold/Flu, Daytime Cold


• Comtrex Non-Drowsy


• Contact Cold and Sore Throat


• Excedrin PM,


• Legatrin PM,


• Unisom with Pain Relief


• Sudafed PE Severe Cold,


• Theraflu Nighttime Severe Cold & Cough,


• Theraflu Warming Relief Nighttime Severe Cold & Cough,


• Benadryl Allergy Plus Cold


• Benadryl Cold (discontinued),


• Contac Day and Night Allergy,


• Benadryl Severe Allergy & Sinus Headache (discontinued),


• Sudafed Sinus Nighttime Plus Pain


• Vicks Nyquil Sinus


• Comtrex Deep Chest Cold


• Sudafed Triple Action,


• Vicodin,


• Norco,


• Lortab,


• Vicodin ES


• Percocet,


• Endocet,


• Roxicet,


• Percocet 5/325


• Pamprin Multi-Symptom Menstrual Relief,


• Pamprin Maximum Pain,


• Midol PMS,


• Midol PMS Maximum Strength


• Theraflu Cold & Sore Throat,


• Theraflu Flu & Sore Throat


• Theraflu Flu & Chest Congestion,


• Vicks Dayquil Sinus,


• Excedrin Sinus Headache


• Darvocet-N 100,


• Darvocet-N 50,


• Darvocet A500,


• Alka-Seltzer Cold and Sinus,


• Ultracet

The safety of many over the counter drugs is dose dependent. Did you know, for example, that if you gave your child the wrong dose of Tylenol it could damage his liver and he might require a liver transplant?

"If I got liquid Tylenol for my baby to bring his temperature down, it must be safe to give him when he gets older, right? I'm very careful not to give my child too much of anything. Certainly, NO dosage of Tylenol liquid, which the doctor recommended for my baby to bring his temperature down and give him some pain relief when he was teething, could harm him when he got a little older, could it? Baby doses, by definition, are lower than doses for older children, aren't they?"

Because it was to be administered by an eye-dropper, i.e. at low drug volume, Tylenol liquid for babies contained a much higher concentration of acetaminophen than other pediatric doses. There have been numerous case reports of toddlers receiving toxic doses of Tylenol because mothers thought that because baby Tylenol was safe for their baby, it must be safe for them as a toddler. But, what the baby got by eye-dropper the toddler might get by the teaspoon, and not just one dose.

I'm sad to report that on July 22, 2010, Daniel and Katy Moore of Ellensburg, Wash., gave their 2-year-old son, River Moore, a Tylenol product for a slight fever that night. About 30 minutes later, River began spitting up blood. The next day, after being rushed to the hospital the night before, doctors pronounced River dead from liver failure. The medicine reportedly contained excessive acetaminophen, which damaged his liver and led to his death.

USA Today News story: Tylenol Claimed Cause of Child's Death

"The FDA was originally planning to discuss the safety of Infant Tylenol, but several drug makers -- including Johnson & Johnson -- preempted any formal action by announcing a decision to discontinue over-the-counter infant drops of medications that contain acetaminophen in May of 2011. See: OTC Industry Announces Voluntary Transition to One Concentration of Single-Ingredient Pediatric Liquid Acetaminophen Medicines However, many bottles still sit on parents shelves and some pharmacies are hoping to sell the last of a now discontinued, popular medication.

Because the FDA did not take formal action on the acetaminophen formulation issue, manufacturers are still free to make infant-strength acetaminophen formulations. Parents should therefore double-check the strength and dosage of acetaminophen -- or any other medication -- before administering it to children."

To check the appropriate dosage for your child and to get more information on the dangers of pediatric Tylenol, check the Tylenol Dosage Chart.

There are, of course, other serious concerns about children and their access to medications at home.

"The U.S. Centers for Disease Control and Prevention (CDC) is implementing a new educational program to help remind parents of the importance of keeping medications -- even those purchased over-the-counter -- "Up and Away and Out of Sight" of young children. Toddlers in particular are at risk from medications and vitamins left within reach, as they have the manual dexterity to open many medication containers, coupled with a very young child's tendency to explore the world orally.

According to the CDC, one in 150 two-year-olds ends up in the emergency room each year due to medication overdose; most of these are the result of the child encountering and ingesting the medicine [1].

Young girl pouring pills

"Up and Away and Out of Sight" encourages parents to follow some basic principles for keeping medications out of the hands of children:

• Keep prescription medications, over-the-counter medications, and vitamins out of reach of children, and in a place where the children can't see the medications.
• Put medications away in an out-of-sight, out-of-reach place every time they're used, even if another dose will be necessary in a few hours' time.
• Listen for the "click" of a properly locked safety cap when closing medication.
• Teach children what medication is, and that they must not take it on their own. It's important to avoid referring to medication as "candy" or a "treat."
• Make sure visitors put their bags, purses, and anything else that contains medication out of reach of children.
• Call Poison Control in the case of a suspected or known medication overdose."

How are these drugs marketed? Read some of the product names and ask yourself: Could these medications possible be dangerous to my child? Let's look for example at the names of some drugs which have recently been recalled:

• Tylenol Extra Strength Cool Caplets
• Children's Tylenol Bubblegum Meltaways
• Children's Tylenol Grape Meltaways

In short - the safety of you, your children and your family depends on your awareness of the contents of many over the counter drugs. A simple overdose of acetaminophen, can cause liver failure and death.

It was a little past noon when Sally and her little boy returned from the park. She fixed him his favorite peanut butter and jelly sandwich while she brought the water to a boil for her regular "Cup-O-Soup", a tasty concoction made by adding boiling water to the dry contents of the styrofoam cup which came with the purchase. It was one of Sally's best quick fixes during a busy day. It came in many flavors and was reasonably priced.Today she had picked her favorite, chicken noodle soup. She placed Timmy's sandwich on the table and he climbed in his "big boy" chair to eat. When the water came to a boil she placed the plastic cup by the sink and poured the boiling water over the dried chicken, noodles and flavorings, waited a couple of minutes, stirring from time to time, then placed the cup on the table, well out of Timmy's reach. The phone rang as she started to sit down. It was her sister, Carol, calling, but she wouldn't find that out until later. As she reached for the phone which hung on the kitchen wall she was startled by Timmy's screams. When she turned back the Styrofoam cup was on its side and a little three year old boy was covered with scalding broth and noodles. The news at the emergency room was not good. He had sustained second degree burns over nearly one-third of his body. The burns were worst where the noodles had fallen on his bare skin because they had trapped the heat.

He would need surgery Sally anguished. What had happened? Had he reached for the soup? It seemed to be out of his reach. Had she bumped the table? Had he? Why did it tip over? National Public Radio reported on December 5, 2011:

"Through calls to a dozen burn units at hospitals across the country, we learned that this is a common phenomenon, with children being the most frequent victims. Eight of the 12 hospitals said they see the injury several times a week. One hospital located in Washington D.C. says they regularly see 5-6 patients a week with the injury, especially during the colder months...Noodle soup is strangely perfect for delivering a serious burn. The sticky noodles cling to the skin, which leads to deeper, more severe burns, according to a study published in 2007."

Is there something inherently dangerous about this product? The cup stands 4.75" tall and has a top diameter of 4.75". In other words, it is as wide at the top as it is tall. However, it sits on a base that is only 2.75" in diameter and the base extends inwards and down from the base of the cup, leaving an overhang. As the cup is filled with boiling water, its center of gravity moves higher. Wider at the top, the top half of the cup, when full weighs more than the narrower bottom half. The more full it is, the more easily it will tip, and it is undoubtedly at its hottest when full. In short, the cup in question is inherently unstable when full.

What are the alternatives? Many soups are available in configurations that are almost "tip proof" In a house with little ones, when shopping for instant soup, buy only the soups with the low profile and the wide, stable base.

Do some manufacturers attempt to make a "tip-proof" container? Next time you're at the grocery store stop by the dairy counter and look at the Yoplait yogurt containers. Why is this cold food sold in containers which are wider at the bottom than at the top? To reduce the incidence of tipping while on the grocer's shelf!

National Public Radio's story: "Why Burn Doctors Hate Instant Soup", by Mara Zepeda.