Coroner Reveals Safety Failures Behind Patient’s Freezing Death on Hospital Rooftop

Update 1/28/25

Chelsea Adolphus, a 28-year-old patient, died from hypothermia after being discovered unresponsive on the hospital’s second-floor rooftop seven hours after going missing from her room. The tragic circumstances surrounding her death have sparked outrage and renewed calls for reforms in patient safety.

Timeline of Events

Wednesday, 4 a.m. Chelsea Adolphus was admitted to Vista Medical Center East, located at 1324 North Sheridan Road, seeking medical treatment.

Thursday, 2 a.m. Adolphus left her patient room on the fifth floor of the hospital. According to Lake County Coroner Jennifer Banek, the door Adolphus exited led to the rooftop and could not be re-entered. It is believed the door did not have an alarm.

Thursday, approximately 8:45 a.m. Adolphus was found unresponsive on the second-floor rooftop, wearing only her hospital gown in temperatures that had dropped to the low 20s Fahrenheit. A patient or a family member of another patient spotted her on the rooftop and alerted hospital staff.

Thursday, 8:45 a.m. - 11 p.m. Adolphus was brought to the emergency room, where hospital staff worked tirelessly to warm her body, which had dropped to a dangerously low 50 degrees Fahrenheit. Despite 14 hours of treatment, Adolphus was pronounced dead at 11 p.m.

Friday An autopsy revealed that Adolphus died from hypothermia due to cold exposure. The final cause of death is pending toxicology results.

Safety Failures and Coroner’s Criticism

Lake County Coroner Jennifer Banek has strongly criticized the safety protocols at Vista Medical Center East, stating, “The door we believe she exited, if you exit that door, you are not able to return back inside of the hospital.” She noted the absence of alarms on the rooftop-access door, raising serious concerns about the facility’s patient safety measures.

Banek, who is also a nurse anesthesiologist and a former caregiver at Vista, shared her ongoing concerns about the hospital’s operations: “I have voiced my concerns about the lack of care and safety measures in place at this facility.” She added, “A death is not the threshold by which we should be measuring the necessity for a call to action.”

A Troubled Hospital History

This tragic incident is not the first controversy surrounding Vista Medical Center East. In 2023, the Illinois Department of Public Health revoked the hospital’s Level 2 trauma designation for five weeks due to insufficient blood supplies and clinical staff. More recently, the hospital furloughed 69 staff members, including patient sitters, citing financial difficulties. Patient sitters are critical in providing one-on-one monitoring for vulnerable patients.

Banek highlighted the potential consequences of these staff reductions: “I had warned during a February 2024 press conference that lives were at stake. In high-stakes industries, like healthcare, we rely on evidence-based practices, transparency, and effective oversight as protective measures to make certain people do not die.”

Vista Medical Center East’s financial struggles also include $1 million in unpaid taxes and overdue payments to vendors and clinical providers. “American Healthcare Systems must be held accountable to provide safe, quality healthcare to Waukegan and its surrounding communities. It has repeatedly fallen short by failing to meet its financial obligations,” Banek stated.

Preservation of Evidence and Investigation

In the wake of Adolphus’ death, the Lake County Coroner’s Office issued a preservation letter to American Healthcare Systems, the hospital’s owner, ordering all paper, video, digital, and electronic evidence to be retained. While the hospital promptly notified the coroner’s office of Adolphus’ death, it failed to contact the Waukegan Police Department. Instead, the coroner’s office initiated the police investigation.

Calls for Accountability and Reform

Vista Medical Center East has applied for safety net hospital designation from the State of Illinois, which would provide additional subsidies to hospitals meeting specific Medicaid and charity care thresholds. However, Banek expressed skepticism about granting financial support to the facility: “While safety net hospital designation from the State of Illinois could help with healthcare costs and improve access to the community, unless there is transparency, money should not be given to private equity entities at the taxpayers’ expense.”

She concluded with a powerful statement: “Hospitals are a public trust, and the public needs to trust in the hospital that serves this community.”

Original Article 1/27/25

A 28-year-old woman named Chelsea Adolphus was found unresponsive on the roof of Vista Medical Center East in Waukegan, Illinois, leading to her untimely death and sparking an investigation into hospital procedures and patient safety measures. 

Patient Goes Missing, Found in Critical Condition

Chelsea Adolphus was admitted to Vista Medical Center East on Tuesday for an undisclosed medical issue. At some point after her admission, she went missing from her hospital room. It wasn't until Thursday morning, around 8:45 a.m., that hospital personnel discovered her unresponsive body on the facility's roof. Adolphus was found wearing only her hospital gown and had suffered from exposure to the cold.

Upon discovery, staff immediately brought Adolphus to the emergency room, where they attempted to warm her body temperature. Despite their efforts, she was pronounced dead at approximately 11 p.m. on Thursday, roughly 14 hours after being found.

Investigation Underway as Questions Arise

The circumstances surrounding Adolphus's death have raised numerous questions about hospital security, patient monitoring, and overall safety protocols. The exact cause of her death remains unclear, and it is still unknown how she managed to access the hospital's roof.

An autopsy has been conducted, but the results have not yet been released to the public. To address the ongoing investigation and provide more information, a joint press conference with the Lake County Coroner's Office and Waukegan Police is expected in the near future.

This is a developing story, Nurse.org will continue to update as more details emerge.