2 Michigan lawmakers seek to regulate hyperbaric chambers after deadly explosion

DETROIT — An effort to license and regulate hyperbaric oxygen chambers in Michigan appears to be picking up momentum after the death of a 5-year-old boy who was inside a chamber in Troy when it exploded, prompting plans by two lawmakers to introduce legislation this spring.

Thomas Cooper was receiving his 36th treatment in a hyperbaric chamber, a pressurized environment filled with 100% oxygen, at the Oxford Center in Troy on Jan. 31 when the machine ignited into a fireball. Cooper was killed within seconds, according to the Oakland County medical examiner's office.

Michigan does not require any oversight of hyperbaric chambers, which prompted state Sen. Stephanie Chang, D-Detroit, and Rep. Sharon MacDonell, D-Troy, to start drafting such legislation in a bid to prevent similar tragedies. About a dozen other states have hyperbaric chamber regulations.

"We're not just pretty sad about what happened, but we're pretty angry about the behavior of the Oxford Center and that they were able to use this equipment with no oversight, no regulations, no licensing," said MacDonell, who lives a few miles from where the explosion occurred. "We're hoping that we can get some regulations going in Michigan over hyperbaric chambers."

Chang and MacDonell have consulted with the Undersea Hyperbaric Medical Society, which accredits facilities that use the chambers, to ensure they are maintained and working properly. They plan to introduce legislation that would limit hyperbaric therapy services in Michigan to facilities accredited by the society.

"Right now, it's kind of the wild west out there. We're understanding that people can just import these machines and use them in beauty parlors or places like this, where they're claiming to just be wellness centers," MacDonell said.

Attorney General Dana Nessel accused the Brighton-based Oxford Center, which operated the chamber in Troy, of routinely operating sensitive and lethally dangerous hyperbaric chambers "beyond their expected service lifetime and in complete disregard of vital safety measures and practices considered essential by medical and technical professionals." The Oxford Center is not among the Undersea Hyperbaric Medical Society's accredited facilities.

Two facilities in Michigan are on the Undersea and Hyperbaric Medical Society's list of accredited facilities, and both are associated with Corewell Health.

Cooper's family retained Southfield-based Fieger law in the wake of the explosion. Managing partner James Harrington said the boy's death was a preventable tragedy.

"Michigan's lack of regulation over hyperbaric chambers left his family vulnerable. We urge state lawmakers to immediately pass strong regulations, mandatory licensing and rigorous safety standards," Harrington said. "No family should ever suffer such a devastating loss again."

The two legislators said they're drafting the bills with a goal of having experts and others start to review them by mid-April.

"We're ... still waiting but hoping that we can get something really solid introduced this spring, but we want to make sure that we're also getting this right," Chang said.

The potential legislation faces uncertain prospects in the Legislature, where Democrats control the Senate and Republicans lead the House.

The office of House Speaker Matt Hall, R-Richland, didn't respond to a request for comment. Two Metro Detroit GOP lawmakers told The Detroit News they are interested in exploring ways to prevent tragedies like the Troy explosion.

Senate Majority Leader Winnie Brinks, D-Grand Rapids, looks forward to reviewing the legislation when it's available, her Deputy Chief of Staff Rosie Jones wrote in an email.

Expert: Legislation might be a first

The Oxford Center is a Brighton-based medical company that advertises the use of its hyperbaric chambers for the treatment of more than 90 conditions, including attention deficit disorder, COVID-19 and Alzheimer's disease. The Food and Drug Administration has only approved the chambers for use in treating 13 conditions, ranging from burns to decompression sickness.

Nessel criticized the center employees for purportedly ignoring safety procedures, tampering with the machines and trying to make money by promoting "unfounded treatments."

Nessel announced this month criminal charges against four Oxford Center employees in connection with Cooper's death. Tamela Peterson, the center's owner and founder; Gary Marken, the primary manager; and safety director Jeffrey Mosteller were arraigned on second-degree murder and involuntary manslaughter charges. A second-degree murder conviction could result in up to life in prison, while an involuntary manslaughter conviction could result in up to 15 years behind bars.

Aleta Moffitt, a technician operating the hyperbaric chamber that exploded, faces charges of involuntary manslaughter and intentionally placing false information on a medical record. All four employees pleaded not guilty.

Raymond Cassar, Marken's attorney, said neither the second-degree murder nor involuntary manslaughter charges make sense because the fire was an accident, "not an intentional act."

At the arraignment, Peterson's attorney, Gerald Gleeson, said both of Peterson's parents used the chambers regularly, arguing that this "tends to discount the idea that she was somehow operating these with reckless abandon."

Michigan would be the first state to require UHMS accreditation for all hyperbaric chamber facilities, said John Peters, the society's executive director. Utah requires accreditation for hospitals that accept state money for Medicaid, the government health care program for the poor, and the UHMS has been trying to reach out to payers to create standards for hyperbaric treatments, Peters said.

Accreditation and licensing of the hyperbaric chambers with the state could prevent what Peters calls "ghost facilities," or those offering hyperbaric treatment that only take cash and don't bill insurance, from operating without oversight.

"I think this is the ... domino that we are looking for to change and increase transparency and accountability for the specialty, and it ultimately results in better care for the patient," Peters said.

The UHMS's accreditation standards are the baseline that facilities should achieve, he said. Tragedies like Cooper's death will be repeated without regulation, he added.

"It'll happen again, until, you know, the regulation, the authorities having jurisdiction, decide to actually do something about it," Peters said. "It is the least regulated part of medicine that I've ever experienced."

The society's executive director estimated that the UHMS could evaluate the 42 hospitals and seven physician offices that practice "legitimate hyperbaric medicine" for accreditation in Michigan within 18 months.

The UHMS participated in the investigation into the Oxford Center fire in Troy. Peters said society experts would have been able to identify problems with the procedures and safeguards if consulted ahead of time.

"We would have seen a lack of physician participation," he said. "We would have seen the gaps — there are many. You could drive a semi truck through the gaps that were involved in that clinic, unfortunately."

One of the legislative ideas is that the state would register and license the hyperbaric equipment, likely through the Michigan Department of Licensing and Regulatory Affairs, to track where the chambers are used at accredited facilities.

"They won't be licensed to work in the state of Michigan unless an organization like LARA says, 'OK, we have checked they have their accreditation,'" MacDonell said. "We'd probably have to have a small fee for that to pay for the work that the agency would have to do. ... Most importantly, licensing would lead to registration and a list of all of the in-use chambers in the state."

Promoting awareness

The Undersea and Hyperbaric Medical Society's accreditation requirements include several industry standards, such as the American Society of Mechanical Engineers' Safety Standard for Pressure Vessels for Human Occupancy and the National Fire Protection Association's health care facilities code. To maintain accreditation, facilities must undergo a survey once every three years, according to the society's accreditation manual.

MacDonell hopes that the legislation can require a physician trained in hyperbaric treatments to be present when the chambers are in operation, and for people receiving treatment to be aware of the conditions the machines are approved to treat.

"The clients should be well aware that the FDA approves hyperbaric therapy for only about 15 conditions, and that they may be using it for an off-label condition," MacDonell said.

Police claim that Cooper's death could have been prevented if the facility had followed standard safety protocols, such as using a grounding wire, according to transcripts from the court. The Attorney General's Office accused the staff at the Oxford Center of manually altering the cycle counter on the chamber that exploded, which measures the machine's lifespan.

"One of the concerns is that somebody could do something like that and then sell it to a third party," MacDonell said. "By licensing and registering the units, the state agency would be able to follow where they are and try to make sure that a very old unit doesn't just keep getting resold and used by people who don't know what they're doing."

MacDonell views the regulations as a safety issue rather than a political one. She chairs the Michigan Legislative Disability Caucus and worries that companies may take advantage of parents of people with disabilities who are desperate for treatments.

"While there might be some folks who might usually be opposed to new 'regulations,' this is one of those where ... the good actors in this space probably actually do want regulation and want there to be some consistency," Chang said. "I think that we'll hopefully see that same understanding from, you know, our colleagues across the aisle."

State Sen. Lana Theis, R-Brighton, said law enforcement's initial reports about the Oxford Center incident are "extremely alarming and heartbreaking."

"As a mother and a lawmaker, my heart goes out to the family affected by this unimaginable loss," Theis said in an emailed statement. "While I will continue to stay closely updated on this case, I fully defer to law enforcement and the prosecutors as they conduct their investigation and determine the appropriate course of action."

The GOP lawmaker said hyperbaric treatments must be held to the highest safety standards.

"I am currently reviewing the existing regulations — or lack thereof — governing these types of facilities and treatments in our state," Theis said. "I am working closely with medical experts, safety specialists, and my legislative colleagues to determine whether new laws or oversight mechanisms are needed to help ensure a tragedy like this never happens again."

State Sen. Michael Webber, R-Rochester Hills, said the Legislature has a moral obligation to ensure that patients' safety and rights are protected.

"This heartbreaking tragedy exposed glaring and dangerous gaps in oversight of these types of facilities," Webber said in an emailed statement. "I am committed to working with my colleagues in the Legislature to protect the most vulnerable from devastating incidents like this in the future."

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