How Massachusetts failed to regulate Steward Health Care

The phone call to Steward Health Care chief executive Ralph de la Torre from the state’s top health official came days after a veteran nurse at Steward’s Good Samaritan Medical Center was fired for a devastating lapse — one that a federal investigation later deemed a violation of basic care.

On Sept. 13, 2023, a triage nurse in the Brockton hospital’s overwhelmed emergency department received a plea for help from a patient in the registration line. Suffering from acute chest pain and shortness of breath, 37-year-old Jennifer Knight believed she was having a heart attack.

But 10 hours into her nonstop shift, with too few nurses to handle a surge of patients, the nurse sent Knight back to the line, without evaluating her or checking her vital signs, according to investigators. Knight collapsed just 20 minutes later and died.