Jessica Zeppa, five months pregnant, the wife of a soldier, showed up four times at Reynolds Army Community Hospital here in pain, weak, barely able to swallow and fighting a fever. The last time, she declared that she was not leaving until she could get warm.
Without reviewing her file, nurses sent her home anyway, with an appointment to see an oral surgeon to extract her wisdom teeth.
Mrs. Zeppa returned the next day, in an ambulance. She was airlifted to a civilian hospital, where despite relentless efforts to save her and her baby, she suffered a miscarriage and died on Oct. 22, 2010, of complications from severe sepsis, a bodywide infection. Medical experts hired by her family said later that because she was young and otherwise healthy, she most likely would have survived had the medical staff at Reynolds properly diagnosed and treated her.
“She was 21 years old,” her mother, Shelley Amonett, said. “They let this happen. This is what I want to know: Why did they let it slip? Why?”
The hospital doesn’t know, either.
Since 2001, the Defense Department has required military hospitals to conduct safety investigations when patients unexpectedly die or suffer severe injury. The object is to expose and fix systemic errors, often in the most routine procedures, that can have disastrous consequences for the quality of care. Yet there is no evidence of such an inquiry into Mrs. Zeppa’s death.
The Zeppa case is emblematic of persistent lapses in protecting patients that emerged from an examination by The New York Times of the nation’s military hospitals, the hub of a sprawling medical network — entirely separate from the scandal-plagued veterans system — that cares for the 1.6 million active-duty service members and their families.