The doors slammed shut on Cardell Davis Sr. just as he tried to step off the elevator at John Peter Smith Hospital.
Davis, who was at the hospital to pick up medication, pried himself free after about a minute, but his rotator cuff was torn, resulting in severe neck and back pain.
He immediately reported the issue to JPS officials. That was in August 2016, more than two years before another elevator at the hospital malfunctioned and crushed a nurse.
“When we step on an elevator we don’t expect the doors to slam closed, we don’t expect it to miss level or suddenly drop,” said Davis’ attorney, Wesley Gould of the Dallas-based Rochelle McCullough law firm. “If an elevator company, a management company or, in this case a hospital, ignored a problem, that’s absolutely terrifying.”
Davis filed a lawsuit last August against JPS, elevator company Motion Control Engineering and maintenance company Thyssenkrupp Elevators. The suit seeks compensation for medical bills.
“Mr. Davis is the type of guy to smile through the pain, but this type of thing won’t get better over time,” said Gould, acting as Davis’ spokesman. “He’s had trouble at work and with his daily life.”
Davis’ injury and a trove of records from JPS and Germany-based Thyssenkrupp Elevators show trouble existed at the hospital before nurse Carren Stratford was crushed Jan. 20 as she tried to step onto elevator No. 29, one of the three purple elevators in the hospital’s tower. She suffered severe brain damage, internal injuries and has had multiple seizures and surgeries, her attorney says.
A week before Stratford, 56, was injured, the hospital received a cease-and-desist letter from Thyssenkrupp’s Rick Karnes, the service operations manager for the company’s Fort Worth branch.
The letter, dated Jan. 11 and delivered Jan. 14, strongly urged hospital officials to “stop the dangerous practice of working on and resetting elevators themselves.”
Karnes wrote in the letter that “an elevator is a complicated piece of equipment and, as such, elevator-related repairs performed by untrained individuals can put the safety of these maintenance personnel and the riding public at risk.”
“Should this practice continue, you will leave us no choice but to evaluate our options under the parties’ agreement and the law,” Karnes wrote.
The letter also confirmed that a Thyssenkrupp technician is at the hospital daily.
In a statement sent to the Star-Telegram on Thursday, Thyssenkrupp Regional President Peter Engwer said: “Hospital staffers, while they may be well-meaning, are complicating efforts to repair elevators. When these staffers reset a stopped elevator, it erases the diagnostic record that is critical for our maintenance personnel to determine the root cause.”
JPS released a statement in response to the letter on Twitter on Thursday evening that said: “We never repair elevators. We save lives. And we never jeopardize the health or safety of our patients, team members or visitors by forcing them to remain in elevators which are incapacitated by TKE’s failure to live up to its obligations. When every minute spent trapped in a broken elevator can be the difference between life and death, JPS team members will respond. What would you have us do, wait minutes, sometimes hours for TKE workers to show up? There is nothing in the contract JPS has with TKE that prevents us from responding appropriately when someone is trapped inside an elevator.”
At a news conference on Feb. 15, JPS Chief Executive Officer Robert Earley said he has looked at changing elevator contractors, but couldn’t provide exact details on how he was keeping his employees and visitors safe.
“I’m doing anything I can do to make sure these elevators are safe,” he said.
Stratford and Davis aren’t the only people who have been injured by elevators at the hospital, according to documents obtained by the Star-Telegram through an open records request.
On May 20, an elderly person suffered a serious head injury because an elevator in a garage didn’t stop level with the ground. When JPS emailed Thyssenkrupp about the injury, the company responded the next day and said that someone would investigate. The outcome of the inspection was not in the records.
The elevator Davis entered, No. 15 in the hospital’s main building at 1500 S. Main St., malfunctioned in January, when it was stuck on the fourth floor with the doors open, “making loud noises,” according to maintenance orders. There were also reports of people getting stuck in the elevator in March and December.
The problems with elevator No. 29, where Stratford was injured, began long before the Jan. 20 incident when the elevator continued to rise as Stratford tried to step on. She lost her balance and was crushed between the 10th and 11th floors, officials said.
Stratford was moved Wednesday from intensive care to a unit that will provide specific therapies to help in her rehabilitation, her attorney said.
A review of records found that people had been trapped in that elevator at least 13 times between March 2018 and January 2019. In most of the cases, work orders say that the elevator was “reset.” After someone got trapped on Dec. 7, the contractor noted that there were “no issues found” with the elevator.
On March 30, multiple people got stuck in the elevator. About five minutes after they were freed, another report of trapped visitors was made.
On May 7, the elevator kept trapping people, a worker said, but it wasn’t put out of service until the fourth complaint, records show.
After Stratford’s injury, Earley sent Thyssenkrupp Elevators several letters expressing his concern over what he believed was a lack of response to the problems. The hospital has posted the letters publicly.
During the Feb. 15 news conference, Earley said that Thyssenkrupp didn’t return phone calls for eight days after the incident.
Thyssenkrupp denied that claim on Thursday, and said its workers were on site within 15 minutes and have been in communication with the senior plant manager of operations at JPS ever since.
“The tragic accident involving Ms. Stratford demands that we all fulfill some very important responsibilities,” Thyssenkrupp’s Engwer said. “Pray for her recovery; determine what happened and why so it doesn’t happen again; and ensure the safe operation of all elevators at JPS hospital. The manner in which JPS has treated us since January 20 suggests that JPS Hospital is more concerned with casting blame than focusing on any of those more important items.”
Multiple messages left with the hospital were not returned.
Earley, at the news conference, mentioned working with the hospital’s board of managers, which oversees JPS and is appointed by the Tarrant County commissioners. Earley supervises the day-to-day operations. Hospital board chairman Charles Powell referred questions about the board’s role in overseeing elevator maintenance and its responsibility of hospital safety to a JPS spokeswoman, who did not respond to messages.
A work order a day
There were at least 80 work orders after complaints of people being trapped in the hospital’s elevators from January 2018 to January 2019, according to documents.
In at least 60 of those cases, people were still trapped when help arrived, according to internal work orders from the hospital and a review of a spreadsheet kept by Thyssenkrupp.
Those same records show that elevator doors didn’t work properly at least 28 times and they suddenly slammed shut another four times.
A representative from Thyssenkrupp said the company has responded to 47 reports of people being trapped over the past year.
“We maintain 47 elevators at JPS Hospital, which means, on average, each elevator at JPS has had only one entrapment over a 365-day period,” the company said. “These ratios fall within the industry norm for elevators of this age and usage.”
A question to JPS about the discrepancy between JPS’ count and Thyssenkrupp’s number was not immediately answered.
The Star-Telegram counted more than 360 work orders for elevators at all JPS locations from January 2018 to January 2019. Those include work orders for general maintenance, such as dead light bulbs and leaky roofs.
The documents also show:
▪ Hospital staff expressed frustration in an email to Thyssenkrupp on Jan. 16 that elevator No. 29 — the one that injured the nurse — had been out of order since December and that the hospital’s leaders were wondering why.
▪ Staff members said they were afraid to ride an unspecified elevator, according to an email sent in March from JPS to Thyssenkrupp. The email didn’t provide details about the problems. There were at least 33 maintenance orders for elevators that month, including people getting stuck and doors not working properly.
▪ Elevators were shut down more than 150 times, ranging from a couple of hours to a few weeks. Elevator No. 29 was out of service at least eight times. Elevator No. 3, a “green” elevator next to the chapel on the first floor, was down at least 18 times, mostly for being stuck.
▪ On Dec. 29, the elevator doors on No. 22 closed too fast, separating a mother from her children. A month earlier, there were reports that the elevator’s doors were “acting erratic” and slamming shut.
The Star-Telegram asked JPS how often its staffers worked on the elevators and whether administrators and Thyssenkrupp were made aware of the work, among other questions about its handling of elevator safety and maintenance.
JPS spokeswoman Diana Brodeur referred a reporter to the hospital’s contract with Thyssenkrupp and forwarded questions to the hospital’s general counsel. No additional response was provided.
Tarrant County officials have recognized the deteriorating condition of JPS for some time. In November, voters approved up to $800 million in bonds for hospital district improvements. A total of $1.2 billion in upgrades is needed, officials have said.
Daily, yearly checks
After Stratford was injured, the hospital started to track daily elevator safety checks. Such reports weren’t made before Jan. 24, or at least weren’t recorded with the maintenance orders. Maintenance employees were told to check that the elevators were stopping correctly on every floor, that the doors were working properly and that there weren’t any abnormal sounds coming from them.
The Texas Department of Licensing and Regulation checks elevators yearly to see that they comply with code and are maintained according to industry standards, a department spokeswoman said. The inspections are performed by state-licensed third-party inspectors who verify code compliance. JPS’ elevators were inspected in April.
Spokeswoman Tela Mange said serious violations require the elevator to be shut off until they are corrected. None of those reports were found in the service records of JPS elevators.
There have been at least 15 lawsuits filed against Thyssenkrupp Elevators in Tarrant County since the early 2000s because of injuries, according to court records. Among the complaints: elevators plunging several floors, people being crushed between doors and others tripping and falling when cars didn’t stop level with the floor.
Asked at the Feb. 15 news conference if he knew about those lawsuits, Earley said, “Understand, the elevator industry is something I’ve become aware of in the last couple of weeks.
“There’s a limited amount of people that do elevator construction or repairs. This company, TK elevators, represents themselves on their website and with others as being the ones of top quality, top standards, top performance. I’m not sure what they do for others, but my confidence is really low in what they do here.”
Kern Lewis, an attorney for Carren Stratford, said on Wednesday that he’s aware of the lawsuit filed against Thyssenkrupp by Cardell Davis last year. He said that he and attorney Frank Branson are looking at initiating legal action.
Asked if he was looking at filing a lawsuit against JPS, or if the firm also holds the hospital accountable, Lewis said, “At this point in our investigation, the responsibility seems to lie with Thyssenkrupp.”
Asked if Thyssenkrupp’s cease-and-desist letter will affect future litigation, he said, “We didn’t know about the letter before (Thursday) and we don’t know yet what specific actions the letter is referring to.” He declined to comment further.
‘Elevators don’t just malfunction suddenly’
The Rochelle McCullough law firm has completed four cases involving elevator injuries in the last two years in Texas, Gould said. Davis’ lawsuit is the first involving Thyssenkrupp.
Those cases involved “a surprising lack of due diligence,” either on the part of elevator maintenance companies or property owners to address problem elevators before an injury occurs, Gould said. The firm is still in the discovery process in Davis’ lawsuit and hopes to learn more about JPS’ elevator maintenance.
“Elevators don’t just malfunction suddenly,” he said. “There’s usually a history of poor maintenance.”
Responsibility for elevator safety depends on the case, he said. Sometimes property owners were unwilling to pay for proper upkeep. In others, the maintenance technicians failed to keep the elevator in running order.
A common defense by property owners and maintenance companies is to argue that the injured person is at fault, Gould said.
“It’s easy to say ‘Well, why weren’t you watching your feet?’” he said. “Well you don’t always look at your feet and you don’t expect your foot to catch on a ledge walking on or off an elevator.”