Note: This story has been edited to include an interview with IU Health CEO Dennis Murphy.
Dennis Murphy, president and CEO of Indiana University Health, has released recommendations from an external review panel following the Dec. 20, 2020, death of Dr. Susan Moore. Recommendations include an increase in diversity, equity and inclusion (DEI) training, the hiring of more patient care advocates and improving communication among health care workers.
“We owe it to our patients to always show up for them, to treat them with dignity and respect, to appreciate their perspectives, and to validate their feelings when they are in our care,” Murphy said in a statement. “We did not live up to these values with Dr. Moore and acknowledge that we have more to do to become a more diverse, inclusive and anti-racist health system.”
The diverse panel was made up of six health care workers — four of whom are Black — from around the country and was established to determine whether Moore, a family medicine specialist, received adequate, compassionate care during her stay at IU Health. Murphy called for an independent review into the case on Dec. 20, 2020. The panel found the “technical care” Moore received at IU Health did not lead to her death, but “cultural competence was not practiced by all providers and several caregivers lacked empathy, compassion and awareness of implicit bias in the delivery and communication of Dr. Moore’s care.”
In an interview with the Recorder, Murphy said those involved in Moore’s care “did not take the time to listen to Dr. Moore and to ask questions to fully understand who she was.”
Moore, 52, was admitted to IU Health North in Carmel Nov. 29, 2020, after testing positive for COVID-19. Despite complaining of difficulty breathing and severe neck pain, she was sent home by IU Health staff Dec. 7, 2020.
Within 12 hours of being discharged from IU Health, she experienced a spike in her temperature and a drop in blood pressure, and she was admitted to Ascension-St. Vincent, where she died three weeks later.
In a 7 ½-minute video posted to her Facebook page Dec. 4, 2020, Moore described her frustrations with her care and allegations of racial bias on the part of her caregivers. Specifically, Moore said a doctor “made me feel like I was a drug addict” when she asked for pain medication.
“I put forth and maintain if I was white, I wouldn’t have to go through that,” Moore said in the video. “This is how Black people get killed, when you send them home and they don’t know how to fight for themselves.”
Several staff members were put on leave during the external investigation, but at the recommendation of the panel, no one involved in Moore’s care was fired. The staff put on leave will be monitored upon their return to work.
Moore’s death sparked national outrage. Local activist group Indy Health Care Workers for Justice issued a statement in December 2020, demanding action from IU Health.
“The racism that tormented Dr. Moore and denied her even basic relief from pain is systemic and existed long before she was subjected to egregious individual acts of health care racism from medical providers at IU North,” the statement read. “… If IU Health believes that Black lives actually matter, that racism is actually a public health crisis … then they will move beyond platitudes and take real action.”
Following the panel’s recommendations, IU Health employees will be required to undergo DEI training by the end of 2021. Murphy said part of the training will include how to change the structure of the health care system and how medical professionals can hold one another accountable.
“I’m not sure you can train [racial biases] out of someone, but you can build systems to be responsive to all patients and their needs,” Murphy said. “That’s been one of the findings that we’ve been able to act on relatively quickly, and we’re expanding patient advocacy. … It’s really about setting expectations, and training people to those expectations and then holding them accountable if they don’t meet them.”
State Rep. Robin Shackleford, D-Indianapolis, chair of the Indiana Black Legislative Caucus, said the findings of the report were alarming.
“The IBLC is disheartened with these findings. Everyone deserves to be cared for with compassion and respect,” Shackleford said in a statement. “These recommendations reaffirm what the IBLC has been advocating for and what the Indiana Minority Health Disparities Task Force recommended in 2020: Indiana’s health care professionals need cultural awareness and implicit bias training. … It is distressing to know that Dr. Moore’s treatment could have been more positive if IU Health had realized this need sooner.”
IU Heath will follow all the panel’s recommendations, Murphy said, and each recommendation will be given its own timeline. Each recommendation and the goals for IU Health will be posted on the hospital system’s website so the public can keep track of progress.
“We are all really committed to this idea,” Murphy said. “… This is not a new set of work for us, this is something we have been committed to and working on prior to Dr. Moore’s case and will be working on it for a long period afterwards.”
Moore’s family, including son Henry, released a statement through their counsel, Steven Langer.
“Susan Moore’s lifelong dream to serve patients and her community as a physician lives on — even after her death,” the statement read. “She believed that all patients, regardless of their background, had a right to receive reasonable and compassionate care. She let the world know when she, herself, felt that she was denied that care. Dr. Moore’s son, Henry, appreciates the genuine thoughtfulness and commitment to change that IU Health has promised to pursue. It is his greatest hope that his mother’s legacy brings about a fair, culturally accountable health care system.”
Contact staff writer Breanna Cooper at 317-762-7848. Follow her on Twitter @BreannaNCooper.