Investigators are cool when 3 vets and a radiologist slowly kill a cat with a misplaced feeding tube

Complaint: Complaint 21-104
Respondent: Hannah Blackman
Premises: BluePearl Peoria

The complainant's cat was losing weight and pulling out fur so the cat was taken to BluePearl and Blackman placed a feeding tube. She says she had to force food into the tube and the cat truly hated it, sometimes throwing up large quantities of phlegm; she often had to hold him down to get him to cooperate. She tells us that her cat actually deteriorated markedly since the feeding tube was placed at BluePearl; she ended up having to take the cat back for hospitalization. They found sepsis, pneumonia, and drew brownish-pink fluid from the chest that the complainant says looked just like her cat's food. The cat was subsequently euthanized. A necropsy showed that the feeding tube wasn't placed at all correctly; the esophagus wasn't even cut into. The necropsy also identified 250 milliliters of "amorphous pasty material" in the thoracic cavity where the tube had been misplaced. The complainant says that her cat was part of her family, that she spent $8000 to try and save him, and that she would never jump to euthanizing an animal. She says that she'll always have to live with the fact that with every squirt of food she was unknowingly torturing and killing her cat because of Blackman and BluePearl's incompetence.

Blackman appears to have lawyered up even more than the usual; even her response is on legal letterhead from Jones, Skelton, and Hochuli (the same firm that represented April Talkington in the 20-30 euthanasia complaint). It says that Blackman is truly very sad about the cat dying. We're also told that Blackman loves animals so much that she pursued a career in veterinary medicine and that she works at both Banfield and BluePearl (both of which are owned by Mars Petcare). She details the events leading up to putting the tube in and says that recovery from the procedure was uneventful. She was assisted in the procedure by Kathryn McAdam (accused in 20-73 of lying to a complainant about the availability of a surgeon at BluePearl). When the cat was brought back to BluePearl by the complainant, veterinarian Sandy Landry (named in complaints 20-08, 20-75, and 20-95) diagnosed the cat with pneumonia but examined x-rays and said the tube was properly placed. We're told the cat "passed away" rather than euthanized. We're treated to a quote of the necropsy report that says that "there is no food within the stomach" and "suspected food material within soft tissue of the left lateral neck suggests inappropriate placement of the esophageal tube into the thoracic cavity." Blackman or her attorney then go on to suggest that as the cat tested positive for FIV the cat was more susceptible to infection; she argues that the cat likely died because of the food causing an infection, but that the cat's infection happened because of FIV and not because of the feeding tube she misplaced. She also reminds us, as she did at the beginning, that "three Veterinarian physicians" and a radiologist thought the tube was in correctly, so we can't really blame Blackman for anything. (Perhaps that makes Blackman look better, or perhaps that just makes her colleagues look bad?)

The Investigative Committee's discussion is truly disturbing. They said that even they could read the x-rays and determine the tube was placed incorrectly; they state that if a radiologist had reviewed the films maybe it could have been avoided. They also noted that Blackman had only done this procedure six times in her entire career. They then said that "mistakes are made" and "appreciated [Blackman's] honesty," stating that they hoped this incident wouldn't dissuade her from placing more feeding tubes in the future. All four investigators, three of whom run their own veterinary practices (Rai at Sugarloaf, Dow at Prescott, and Sidaway at Desert Ark), voted to dismiss with no violation! The Board disagreed with letting Blackman walk and found her guilty of medical incompetence; they required her to take three hours of continuing education in how to place tubes. (It doesn't appear there was any broader discussion or investigation into the entire premises given that this was apparently such an obvious mistake.)

Motions

Investigative Motion: Dismiss with no violation

Source: August 8, 2021 PM Investigative Committee Meeting
People:
Clarissa Reiman Respondent Attorney
Hannah Blackman Respondent
Roll Call:
Adam Almaraz Aye
Amrit Rai Aye
Brian Sidaway Aye
Cameron Dow Aye
Result: Passed

Board Motion: Disagree and find violation and offer consent agreement

Source: September 9, 2021 Board Meeting
Proposed By: Robyn Jaynes
Seconded By: Darren Wright
Roll Call:
Darren Wright Aye
J Greg Byrne Absent
Jane Soloman Aye
Jessica Creager Aye
Jim Loughead Aye
Nikki Frost Aye
Robyn Jaynes Aye
Sarah Heinrich Absent
Violations:
ARS 32-2232 (22) Medical incompetence
Result: Passed

Board Motion: Offer consent agreement

Source: September 9, 2021 Board Meeting
Proposed By: Robyn Jaynes
Seconded By: Jim Loughead
Roll Call:
Darren Wright Aye
J Greg Byrne Absent
Jane Soloman Aye
Jessica Creager Aye
Jim Loughead Aye
Nikki Frost Aye
Robyn Jaynes Aye
Sarah Heinrich Absent
Result: Passed

Board Order: Order 21104 HANNAH BLACKMAN, DVM

Source: Order 21104 (November 11, 2021)
Violations:
A.R.S. ยง 32-2232 (22) Medical incompetence for improper placement of the esophageal tube.
Penalties:
Probation (1 year)
Continuing education (3 hours in esophageal tube placement)

The primary source for the above summary was obtained as a public record from the Arizona State Veterinary Medical Examining Board. You are welcome to review the original records and board meeting minutes by clicking the relevant links. While we endeavor to provide an accurate summary of the complaint, response, investigative reports and board actions, we encourage you to review the primary sources and come to your own conclusions. In some cases we have also been able to reach out to individuals with knowledge of specific complaints, and where possible that information will be included here.