A Three-Year Search for Accountability

One Family’s Journey Through Florida’s Medical Oversight System

What This Story Demonstrates:

• A fatal hospital incident required three years of administrative effort to investigate. In Florida, the statute of limitations for Wrongful Death cases is two years, which begins when someone suspects negligence has occurred.
• One state agency ultimately substantiated misconduct, while another closed the case without explanation.
• The investigative and analytical work that led to that finding was performed largely by the victim’s family rather than the State.

This story is not presented as an emotional appeal. It is presented as a documented example of how Florida’s administrative oversight system functions when a citizen attempts to report suspected medical negligence outside the courtroom.

Reader Orientation

This account illustrates the practical challenges Florida families can face when attempting to report suspected medical negligence through the state’s administrative oversight system. My story is not an outlier. Over the past six years, I have spoken with many other families who encountered the same ineffective process I encountered. This tells me the system is broken.

Disclaimer

The story you are about to read is a true account of the journey I undertook through the administrative systems of the Florida Department of Children and Families (DCF) and the Florida Department of Health (DOH) following my mother’s death in May of 2020. Although I use the pseudonym “Alex” in this narrative, the events described here are drawn directly from my own experience.

Complaints involving suspected medical negligence are generally expected to begin with the Florida Department of Health, the agency responsible for licensing and regulating healthcare professionals, or with the Agency for Healthcare Administration (AHCA), which regulates and disciplines facilities. However, at the time my mother died, I had recently discovered Florida Statute §768.21(8), which prevented me from bringing a civil case against the hospital or the nurse involved in the incident. So, in my attempt to seek accountability in my mother’s case, I filed a complaint with DCF alleging abuse and neglect of a vulnerable adult in the care of the hospital and the nurse assigned to her care.

Like many surviving family members placed in this position, I did not understand how Florida’s administrative complaint system was structured or which agency was responsible for reviewing the conduct of healthcare professionals.

As a result, my initial complaint was filed with the Department of Children and Families. Over the next two years, I worked with DCF investigators in an effort to understand what had happened to my mother and whether the circumstances surrounding her death had been properly investigated.

At no point during that period was I informed that the appropriate agency for a professional licensing complaint was the Florida Department of Health.

Only after nearly two years of correspondence, an investigation, an appeal, and a second investigation was I told that the matter should have been filed with the DOH from the beginning. By that point, the process had already become a long and complicated administrative journey.

What follows is a reconstruction of that journey, drawn from more than 300 pages of email correspondence between me and these two state agencies.

The Incident

My mother, Wynelle Glickstein, died on May 20, 2020, following injuries she sustained during a fall while hospitalized at Winter Haven Hospital.

According to hospital documentation, my mother had been classified as a high fall-risk patient, a designation that required specific safety precautions under the hospital’s own policies. One of those precautions was the use of a fall prevention bed alarm designed to alert staff if a patient attempted to get out of bed without assistance.

What I later learned from the medical records and witness statements was that the alarm system intended to protect my mother had been disabled. Upon discovery, a fellow employee informed the assigned nurse that the alarm was disabled, yet the nurse took no corrective action.

Shortly afterward, my mother fell.

The fall triggered a cascade of medical complications. An undetected internal bleed developed while she remained on anticoagulation therapy. Her condition deteriorated rapidly. Within days, I had her transferred to hospice care so that my family could say goodbye. We were not allowed to enter the hospital due to recent COVID-19 restrictions.

She died shortly thereafter.

For my family, grief quickly turned into a search for answers.

Entering the System: The Department of Children and Families

Because my mother was considered a vulnerable adult, the incident was supposed to trigger an investigation by the Florida Department of Children and Families. However, because the hospital never reported the incident, no investigation began until I phoned DCF the day before my mother passed.

A DCF investigator, Ms. Chaka McDaniels, arrived at the hospice facility just hours before my mother drew her final breath to take my initial statement.

It took two months, with multiple phone calls and electronic correspondence, for the hospital to comply with State law and provide the medical records I had requested. I finally hired an attorney to write a demand letter to the hospital. Once I received them, I began reviewing my mother’s final days through what was documented in these records. What started as a simple attempt to understand what took place both before and after my mother’s fall soon became a painstaking six-month reconstruction of events.

While I waited to hear back from the DCF investigator, I spent as many as 16 hours a day reviewing the electronic medical record, building a timeline, comparing nursing notes, medication records, incident reports, and physician documentation. What I discovered raised serious questions. The hospital’s own records contained wildly inconsistent reporting of the incident.

Descriptions of the fall conflicted with each other. Documentation regarding fall-prevention measures was either missing or incomplete. Staff notes indicated that my mother had been classified as a high fall-risk patient, which required safeguards under hospital policy, while risk management notes stated that the bed alarm had been disabled, supported by notes from two doctors stating that my mother’s injuries were “iatrogenic,” meaning, “we did this.”

I compiled these findings into a structured submission for DCF investigators. The materials I provided included:

• detailed timelines
• hospital documentation
• physician notes
• photographs of my mother’s injuries
• analysis of contradictions within the medical record

These submissions were not emotional complaints. They were structured analyses tied directly to the hospital’s own records.

After submitting this material, communication from DCF largely stopped.

Months later, when I contacted the investigator to ask about the status of the case, I was told the investigation had already been closed.

When I asked how to obtain a copy of the investigative report, I was directed to an online records request process that required multiple rounds of verification and additional documentation before the report was eventually released.

When I finally received the report, I discovered that many of the issues I had documented were not addressed in the agency’s findings.

Escalating the Investigation

I contacted the investigator to ask whether the case could be reopened.

I was told it could not.

When I asked whether there was an appeal process, I was told there was none. After that, DCF cut off communication with me.

Determined to pursue the matter further, I began searching for someone higher within the agency who could review the investigation.

After several weeks of attempting to identify a supervisory official, I eventually spoke with Roy Carr, the State Director of Adult Protective Services.

During our conversation, I explained that the investigation appeared to rely on incorrect medical assumptions and failed to reconcile key evidence already in the agency’s possession, including the medical record itself.

Mr. Carr advised me that if I had new evidence, he was willing to review it. I compiled my evidence again, this time binding it in a notebook and sending it directly to him through the US Postal Service, Priority Mail, with Return Receipt Requested.  Once the USPS website notified me that the package had been delivered, I phoned Mr. Carr once again.  He confirmed receipt and told me he and his deputy were reviewing the materials I had submitted and would get back in touch once their review was complete.

Two days later, I received a call from Mr. Carr. His response was direct:

“We dropped the ball on this one.” He assured me that the investigation would be reopened, and it was.

Following the second investigation, the agency reversed its earlier conclusions and substantiated misconduct by the nurse involved in the incident. Finally, after two years of work, I believed that someone would be held accountable and that justice had been served for my mother. But then the other shoe dropped. As I read the final part of the second DCF investigation, all of my enthusiasm drained from me. The final paragraph stated that no further action was necessary because the victim was dead. In other words, Mom was no longer endangered because she died from her injuries.

I phoned Mr. Carr to express my concern, and he told me that his agency did not have the authority to discipline the nurse and that if I wanted to pursue that course of action, I would need to file a complaint with the Department of Health.

For me, this moment confirmed something important: the initial investigation had failed not because the evidence was missing, but because it had not been properly analyzed. However, the resolution created a new problem. DCF had no authority to discipline the nurse involved. That authority belonged to another agency. So now I would need to file a complaint with the Florida Department of Health. I believed this would move quickly with the DOH since DCF substantiated the neglect.  But I was wrong.

Starting Over: The Department of Health

By the time I contacted the Department of Health in early 2022, the two-year statute of limitations had run on a Wrongful Death case. If Florida law allowed me to bring a suit, the delays with DCF would have derailed that possibility. But I followed Mr. Carr’s advice and filed my complaint with the DOH. I believed the most difficult work had already been completed. The evidence had been gathered. The medical record had been analyzed. One state agency had already acknowledged investigative failures and reversed its conclusions.

I assumed the Department of Health would review the same evidence and determine whether disciplinary action against the nurse was warranted.

The process began with a complaint form.

I completed the form and submitted extensive documentation, including the final DCF investigative report.

Over the following weeks, I exchanged emails with a DOH investigator, providing additional documentation and updating the agency on the probate process through which I was being formally appointed as the personal representative of my mother’s estate.

Then communication stopped.

Emails went unanswered. Phone calls were not returned. Months passed without confirmation that the case was even being investigated.

Eventually, I contacted my mother’s State Senator's office for assistance. Within two hours of the Senator’s inquiry to the Department of Health, I received a phone call from a senior analyst in Tallahassee who assured me that he would personally oversee the case going forward. The sudden responsiveness revealed something troubling: the system appeared to function only when legislative authority intervened.

Administrative Confusion

Over the following months, my case moved through multiple investigators.

Each transfer required me to:

• reintroduce myself
• resubmit documentation
• re-establish my legal standing as personal representative of the estate

On multiple occasions, I received requests for information I had already provided. At one point, I received written correspondence asking for the name of the personal representative of my mother’s estate, even though I had already submitted certified court documents confirming that role. Eventually, the case was assigned to a medical malpractice investigator, who thoroughly reviewed the evidence and prepared a report for submission to the Department’s legal review process.

In January 2023, I received notice that the Department’s legal staff had recommended the case for review by a Probable Cause Panel. This was the final step before potential disciplinary action by the Board of Nursing. After nearly three years of investigation and documentation, I believed accountability might finally occur.

The Decision

In March 2023, I received a letter stating that the Probable Cause Panel had determined there was no probable cause and that the case would be closed. No explanation was provided. When I asked for clarification regarding the panel’s decision, I was informed that the investigative file was confidential because probable cause had not been found.

I was, however, given 60 days to submit an appeal. But after asking how I could appeal when the DOH refused to tell me what evidence the panel believed was missing or insufficient, I was sent a statute number and told to “Govern yourself accordingly.” Despite not knowing what I was appealing, I prepared and submitted a forty-five-page appeal citing the relevant statutes and administrative rules to the best of my ability as a layperson.

Within an hour of receiving my appeal, I received an email from the DOH stating that it had been rejected. I was informed that the case would remain closed and that the Department had no further obligation to communicate with me.

What This Experience Reveals

My experience illustrates a broader structural problem within Florida’s healthcare oversight system.

Families who suspect medical negligence often begin by contacting attorneys. In many cases, they are turned away, not necessarily because the facts lack merit, but because Florida law limits the damages available in certain wrongful death cases, specifically those that fall under FS §768.21(8). Administrative agencies are then presented as the alternative path to accountability. But the administrative system assumes that complainants already understand complex medical and legal concepts such as:

• the medical standard of care
• deviation from that standard
• causation
• professional scope of practice
• jurisdictional authority among state agencies

Most families do not possess this knowledge. How could they? It takes three years of law school and many years of practice for a lawyer to understand the complexities of administrative law. This does not even address the difficulties of the DOH online portals people are forced to use to file their complaints, or the multiple attempts to reach a living human being to answer questions, something requiring an elected Representative or Senator to step in and facilitate the process.

Once a complaint is filed, communication often stops. Investigations proceed without further input from the complainant, leaving them wondering whether they communicated their story correctly. Decisions are made behind closed doors and are rarely, if at all, explained. For many families, the result is silence until they receive a letter in the mail telling them that the case is closed, with no further explanation.

From the agency’s perspective, complaints fail because they lack sufficient evidence.

From the family’s perspective, the system appears impenetrable.

The deeper truth is that the system often requires grieving families to function as investigators, analysts, and legal researchers, roles they were never prepared to perform.

The Question for Lawmakers

My experience does not necessarily prove that the nurse involved in my mother’s care should have been disciplined. But it does reveal something more troubling. It reveals a system in which a private citizen spent three years reconstructing the investigative record of two state agencies simply to have the evidence considered. Shouldn’t that be the work of the regulatory agencies already funded by the citizens?

When accountability depends on extraordinary persistence, technical competence, and years of unpaid labor by grieving families, the system is no longer functioning as a public safeguard.

It becomes a system of attrition.

And that is the problem lawmakers must confront if reform is to be meaningful.