by Ann Rule
On Friday, August 22, Dan and Sarah had their movie-popcorn family night camp-out in the living room with Nathan and Amanda. It was almost Labor Day. School would be starting for Nathan soon, and Amanda would go to preschool.
Dan Smith drove Sarah to Anthony Pignataro’s office on Monday morning, taking a book with him to read in the waiting room while she was in surgery. He sat down with her to wait, and then she was taken to the back room, where she said the doctor would give her some “relaxing” pills. Dan was surprised when she came back out to the waiting room. He could tell the pills were affecting her; she was beginning to feel woozy.
Evidently Janie Krauss was late and they had to wait for her to arrive. When she came rushing in, Sarah was taken back through the closed door to have her surgery. Dan prepared to wait, but Dr. Pignataro came out several times and urged him to “go do some errands or something, and you can come back later.”
“I didn’t want to go,” Dan said. “But finally he said he was going to lock the door. He didn’t exactly throw me out, but it was clear he wanted me to leave.”
In his book, Anthony, writing as “Debbie,” would recall that August 25 was the day his“world fell apart.” For Sarah Smith, it was far worse than that.
Debbie Pignataro had been called on to assist her husband that morning. Wearing hospital scrubs, she had to keep a sharp eye on the pulse-ox device on the patient’s finger and to check that her blood pressure was stable. Janie Krauss was in charge of adding meds to the tube going into Sarah Smith’s arm, and seventeen-year-old Tom Watkins stood at the head of the operating table, mostly observing, but ready to run an errand if Anthony requested it. There was no anesthesiologist, no nurse-anesthetist, not even a registered nurse present.
The TUBA procedure began. But within less than an hour, sirens screamed as emergency medical units arrived at Dr. Anthony Pignataro’s office. The scene in the surgical area in the basement was one of horror and chaos. No one who was there would ever forget it.
10
Dan Smith came back to Pignataro’s office between two and two-thirty. As he walked into the waiting room area he heard someone whispering. “They were saying, ‘The husband’s here,’ and a woman who said she was Debbie Pignataro asked me to go with her into a back office.”
Debbie had taken a deep breath, trying to find a way to begin. Finally she said, “We’ve had a little problem…”
Dan looked at her quizzically. He wasn’t worried yet.
“Your wife was not breathing—but she’s breathing now,” Debbie hurried to reassure him. “She’s on the way to the hospital. I’ll drive you.”
Why would she want to drive him to the hospital? Dan started to explain that he was perfectly capable of driving himself, but there was a funny pinched look on the doctor’s wife’s face, and he followed her to her car.
It wasn’t until he got to the hospital and a priest and nun came to talk with him that Dan Smith realized his world had tilted off center and something was terribly wrong. Someone led him to the intensive care unit, and he saw Sarah lying there with several tubes coming out of her body.
“It was just like somebody grabbed my ankles,” he remembered. “I fell on my knees with shock. I realized then.”
Sandy Smith, still on the job at the school where she worked, could hardly recognize her son’s voice on the phone. Usually it was soft and calm. Now he was screaming something over and over that she could not understand.
And then she did. Dan was shouting, “She’s flat-lined! She’s flat-lined!”
At first, she couldn’t figure out who he was talking about. Her husband, Tim, had been really sick, but he had recovered rapidly from the gallbladder attack. Sarah was supposed to have her surgery on this Monday, but her daughter-in-law had laughed at Sandy’s concern, “It’s not even a real operation,” Sarah had said. “I won’t even be put under anesthesia. He’s just going to give me a local and something to relax me.”
No, Dan couldn’t be talking about Sarah. Sandy had worked as a medical assistant herself, and she knew what “flat-lined” meant. No brain activity, no heartbeat or breathing unless a machine did that for the person. Sarah was only 26 years old, and she was healthy.
But Dan was talking about Sarah. His voice quivered with shock as he said he was with her at Buffalo Mercy Hospital, and he wanted his family to come. Sandy called her daughter, Paula, and they raced to the hospital as fast as they could get there. Barb Grafton, Sarah’s mother, was already there with Dan. Both of them were crying.
All Sandy could think of was that Barb had lost her son, and now she might lose her daughter.
Sarah was in a little cubicle, surrounded by curtains, in the hall of the intensive care unit. When Sandy Smith was allowed to look in, she gasped, “Oh, God!”
Sarah lay pale and still, a respirator hooked up and breathing for her. It didn’t seem possible to Sandy that her spunky little daughter-in-law could be so still and unresponsive.
A nurse looked up at Sandy, and when their eyes met, Sandy knew the outcome was going to be as bad as it could get.
“Get a lawyer,” the nurse said softly. “Get a good one—this guy has put five people in the hospital in the last few weeks.”
“Will she get better?” Sandy asked, a hopeless tone in her voice.
“Not unless she comes back very soon,” the nurse said, but her face said more. Sarah’s chest rose and fell in the odd, mechanical way a patient on a respirator breathes. Sandy kept seeing the image in her mind of Sarah only nine days earlier as she grinned and said, “This is the last time I’m ever going to look like this in a bathing suit…”
Sandy and Paula went to the waiting room to join Dan and Barb, and saw that Dr. Pignataro and his wife, Debbie, were waiting there, too. Debbie Pignataro appeared to be in shock, but the doctor seemed calm.
“He kept talking about how everything was going to be all right. I asked him what had happened, but he didn’t give me any specific answers,” Sandy Smith remembered.
Pignataro turned to Dan. “I don’t know what happened,” he said plaintively. “Was she taking anything?”
“No—no!” Dan said. “What happened?”
“I don’t know what happened,” the doctor kept repeating, as if he had nothing to do with what was wrong with Sarah.
Sandy thought that Debbie was trying to shelter her husband from the bleak outcome of Sarah’s condition. She appeared to be a gentle woman, and her skin was pale with concern as she scanned his face. Of the two of them, Debbie Pignataro was the one who seemed upset and aware of the tragedy that was taking place. The doctor only tried to make excuses for himself. Whatever had happened, he wanted everyone in the room to know that he was in no way responsible.
Debbie told Sandy that she had been in the operating room during Sarah’s surgery. “She said she’d worked as a medical assistant in doctors’ offices—but I’d done that, too, and I knew she wasn’t certified to assist in operations because I wasn’t.”
She knew that Sarah had been very impressed with Dr. Pignataro, but now Sandy found him too glib and calm, given the circumstances. “Maybe it’s because I’m older and I’ve got more experience, and it’s harder to fool me,” she said. “Sarah was only twenty-six, and she totally trusted him.”
They all waited, forming a mostly silent tableau: Sarah’s family and the Pignataros. The waiting room was hushed as the clock ticked and there was no change at all in Sarah Smith’s condition.
The days wore on, and Sarah didn’t wake up. As he had with Connie Vinetti, Anthony Pignataro came into Buffalo Mercy Hospital to check on Sarah Smith. The nurses there recognized him, and they moved to block his access to Sarah. Dan called the law firm where Sarah worked, and they quickly arranged to ban Pignataro from the hospital premises.
Dan Smith could not bear to go back to the little house where they had been so happy. He and Nathan and Amanda moved in with Sandy and Tim Smith while they waited to see what would happen, but Dan spent all his time at the h
ospital, coming home only to shower and change clothes. Dan refused to even think that Sarah might be in a permanent coma.
Sandy took care of the children while Dan and Barb, and later Sarah’s father, Russell, who had flown in from Iowa, waited at Buffalo Mercy. Nathan was 7, and he knew something was wrong when the family decided it would be best not to take him to see his mother. “My mom’s really sick,” he murmured, half as a statement of fact and half as a hopeful question.
But they all thought he would be more frightened if he saw the silent bloated shell that Sarah had become. “It’s not a good idea for you to visit her right now,” they told him, and he answered sadly, “My mom’s not going to come home.” He knew it, but he didn’t want to talk about it.
Amanda was too young to understand. She was getting a lot of attention from friends and family who had gathered to wait and pray, and she seemed to feel safe, hopping happily onto the laps of women who tried to comfort her.
The doctors told Dan that there was no chance that Sarah was coming back to him. If she lived, she would “be a vegetable.” He couldn’t accept that. It simply wasn’t possible that she could have been healthy and happy and not even apprehensive the last time he saw her, and now have no brain waves or any sign at all that she was aware of him or their children.
The doctors were cautiously advising him to let her go, but he couldn’t do that. Not yet.
Gradually, gradually, Dan began to think that maybe he could let Sarah go free of the body that trapped her, but he still went back and forth in an agonizing inner dialogue. He had heard of people in comas who were oblivious to anything around them for months—years even—who suddenly woke up. What if that could happen to Sarah? If that should be true, it would be terrible for him to turn off her ventilator. But if she was suffering needlessly, if she had already gone on without him—that part of her who thought and felt and loved—it wasn’t fair to keep her alive.
Dan talked to Sarah’s parents, because they had to be part of the decision, too. There could be no more agonizing decision for any of them.
The press hovered, wanting to know how Sarah Smith was doing.
Anthony Pignataro returned to work as usual. He had other surgeries scheduled, and he saw no reason not to carry on. When his staff asked him if he was doing all right, he shrugged off their concern.
“That could happen to anyone,” he said. “We just have to go on.”
In fact, he did a few more TUBA procedures for breast augmentation. He knew that the New York Department of Health’s Medical Board was watching him and that they might try to shut him down. He said as much. “They’re probably going to take my license,” he commented matter-of-factly. “I need to do as many operations as I can—get some money put away.”
Debbie was heartsick. Anthony had left it up to her to tell Dan Smith that his wife had been rushed to the hospital. She had wondered how in the world she could tell him. She agonized over the impossible task Anthony had delegated to her. Once again, Debbie had been left to clean up after one of Anthony’s disasters. She had no idea what had gone wrong, and she had listened as her husband cried that he didn’t understand it either. Debbie hadn’t known what to think as she sat in the suddenly silent office with the surgical suite still in complete disarray. Anthony was a good doctor. She knew he was. He had to be after all those years of medical school, all those years of residency programs.
Hadn’t she warned him in time that Sarah was in trouble? She wondered if the disaster might be her fault. No, she had watched the blood pressure monitor and the pulseox so carefully, and Anthony had been annoyed with her when she tried to tell him that something was wrong.
She tried to tell herself that Anthony felt terrible about what had happened, just as she did. But she had come to know what was going on in Anthony’s mind, and she wasn’t sure. Maybe he just didn’t feel things the way other people did. He’d put up a kind of a steel wall around himself when his father died, and he kept moving forward, doing whatever he wanted to do.
He spent more time doing body-building exercises at his sports club, and he drank a little more tequila in the evening, but he didn’t seem worried or remorseful.
Debbie herself was so concerned about other people that she could not comprehend someone who didn’t care at all. She had been making excuses for Anthony for decades—not only to others but to herself. And he had been keeping secrets from her for just as long. There were so many things in his life and in his career as a doctor that she didn’t know.
It was Labor Day, 1997, when Dan Smith made the most anguished decision any man has ever had to make. He told the doctors that he would sign the permission form to take his wife off the respirator. Sarah Smith legally died on September 1.
For the first time, Dan went back to their little house in Depew to spend a few hours alone and try to get his head straightened out. He had to find a way to tell his children that their mother was gone forever.
“But it was already on the news,” Sandy Smith recalled. “And we all knew Nathan and Amanda needed to hear it from Dan first, so he hurried to our house. Nathan was stoic. He didn’t cry—he just wanted to go upstairs and be alone with his cousins. Our oldest girl, Laura, has a son, Michael, who is a year older than Nathan, and those little boys kind of sat together quietly. Amanda cried.
“I heard her tell one of her little playmates that moms die when they get to be 26—that her mother was probably going to die, too, when she got that old.”
They had a wake for Sarah, and crowds of mourners attended her funeral in the Hoy Funeral Home in West Seneca. It was forty miles from the site of her funeral to the cemetery where she was to be buried next to her brother. The church where she and Dan were married was just across the street. The procession of mourners’ cars stretched out for more than a mile.
The television cameras followed them.
* * *
Sandy Smith became a substitute mother for two little children, decades after she’d raised her own.
“And all those flowers that Sarah planted,” she said, “kept coming up long after she was gone. She worked so hard on her garden; it would have made her happy to see them, but it made us cry. Dan never lived there again, but his sister, Paula, did—until he could sell it.”
“Everyone kept telling me to sue,” Dan recalled. “But it wasn’t going to bring Sarah back. My goal was only to be sure that people knew there were doctors like Pignataro out there. I didn’t even push to have him go to prison for the maximum time because I knew he had two kids at home. I didn’t want to take him away from his family. I thought if he just lost his license and couldn’t practice, we’d have one really bad doctor out of the system.”
For a time, at least, that wouldn’t be a concern. On August 29, 1997, Anthony Pignataro’s license to practice medicine was suspended by the New York State Department of Health. He had been correct in assuming he wouldn’t be able to continue operating on patients when he rushed to increase his income before that happened.
His malpractice insurance made a settlement with Dan Smith, and Dan put it in a fund for his and Sarah’s children.
Part Five
Last Dance
11
Whathadhappened to Sarah Smith to cause her brain to die? The answers weren’t easy, and it would take the combined efforts of medical investigators, skilled detectives, and clever prosecutors to find them. They could not bring Sarah back, but they wanted to know whether she had died because of some undetected prior medical condition or through an outrageous instance of medical malpractice.
The first of the investigators were the local police. Captain Florian Jablonski and Detective Robert Fiscus of the West Seneca Police Department visited Anthony Pignataro in his office at 531 Center Road in their town on August 29, 1997, two days before Sarah was declared dead. At ten that Friday morning, they were ushered into the doctor’s office. He told them that his attorney had advised him not to talk to anyone about Sarah Smith. But then he smiled and said th
at since Jablonski and Fiscus were detectives, he would be glad to talk with them.
Asked who was present during Sarah’s surgery, he said that Janie Krauss, the LPN who worked for him, was there and that his wife, Deborah, had acted as a gofer to get the instruments as he needed them. He explained Sarah’s operation to the two detectives, saying that he had given her a local anesthetic and then something that allowed her to drift in and out of consciousness.
Pignataro gave them a description of the TUBA procedure. But somehow, he said, something had gone wrong, and he detailed how carefully he had given emergency aid to Sarah Smith when she went into cardiac arrest.
Doing breast surgery through the belly button sounded very peculiar to the two detectives from West Seneca, but Anthony Pignataro assured them that it was common in California and that it would soon be “very popular” in New York State.
When his patient had suddenly stopped breathing, he had administered immediate resuscitation efforts, of course, and instructed his office personnel to call for help. During this interview, four days after Sarah Smith went into a coma, Anthony assured the investigators that his prime concern had been for his patient and her recovery. But now, he said, he had to apologize to them because he had patients to see, and he could give them no more of his time.
Two days later, Sarah Smith was dead.
Frank Clark, the district attorney of Erie County, New York, oversaw an office with numerous assistant district attorneys to handle the different divisions. Like any city, Buffalo had its felonies and misdemeanors, domestic abuse, sexual assaults, arson, robberies, drug violations, and, of course, homicides.
Although there were ongoing investigations into the medical skill—or lack of it—of Anthony Pignataro, M.D., before September 1, those had been under the aegis of the New York State Department of Health. With the death of Sarah Smith, the Erie County D.A.’s office was drawn into the case of a doctor who had a disturbing history of patient care. While the Department of Health works with local law enforcement departments, the Buffalo-based D.A.’s office has sixteen of its own special investigators, most of them seasoned detectives with years of experience in other agencies. Jonathan Coughlan, Chief of the Special Investigations/Prosecution Bureau at the time, called two of the D.A.’s prime investigators and asked them to look into Sarah Smith’s death.