SOVEREIGN ISLANDS — A special report


The New York Times
Published: October 31, 1999

SOVEREIGN ISLANDS — A special report.; Getting Sick on the High Seas: A Question of Accountability

Shortly after midnight last Feb. 25, James Curtis, a 59-year-old retired businessman from Maryland, was found unconscious in a public restroom aboard the Sensation, one of the 14 ships of Carnival Cruise Lines. He was revived by the ship’s nurse and taken to the infirmary.

Over the next six hours, Mr. Curtis drifted in and out of consciousness, all the time complaining about worsening stomach pains. The nurse and a doctor hooked him to an IV and gave him a breathing tube. But they missed that an abdominal rupture was causing him to bleed to death. Such ruptures are often fatal. But even had they recognized the blood loss, they had no equipment to give him a transfusion.

“It was like watching an avalanche coming at me and not being able to stop it,” his wife, Irma Curtis, said as she recalled watching helplessly as he finally died at 6:50 that morning.

Medical emergencies are terrifying anywhere. But when something goes seriously wrong on a cruise ship hundreds of miles out at sea, passengers are on their own more than they might imagine. Even on the largest ships — floating towns with as many as 3,100 passengers and 1,500 crew members — those aboard must rely on infirmaries that are better equipped for sunburn and seasickness than for heart attacks. And they are often staffed by doctors who are not qualified to work in the United States.

When it comes to medical care, the cruise ships to which millions of Americans flock every year are free of any United States regulation.

Though more than 90 percent of the passengers are Americans, the ships are governed by the laws of the countries where they are flagged, mainly Panama, Liberia and the Bahamas. The $12 billion industry pays virtually no United States corporate taxes and can ignore many American laws governing labor standards, the environment and security.

There is no international oversight of medical care because maritime law does not require cruise ships to provide any for passengers.

The result is that the fast-growing industry has been left to establish its own guidelines, which are voluntary. In response to pressure from the medical establishment, the care has improved lately. But the quality of doctors and the sophistication of equipment vary significantly.

The major cruise lines have doctors, nurses and infirmaries on their ships. But the medical personnel are independent contractors, not employees, and courts have ruled that the lines are not liable for their actions.

Many shipboard doctors have degrees from foreign medical schools and lack the minimum training to practice in American hospitals. Hiring practices can be slipshod. Doctors can be on call 24 hours but are often paid substantially less than doctors in the United States. Most cruise lines lack formal processes for reviewing a doctor’s work.

This year more than five million people will take cruises out of American ports on ships sailing under foreign flags, a record. And the average age of passengers has been declining, to 50, reflecting the greater popularity of cruise vacations among families.

Few of the passengers will ever think about medical care on the ships, and the overwhelming majority of those who do will not suffer serious injury or illness. But hundreds of passengers each year do experience medical emergencies, and 20 or so die, according to medical experts and statistics from the cruise lines and the medical examiner’s office in Miami, the nation’s busiest cruise port.

In most emergencies, passengers recover, some to write glowing letters of praise to the ship’s staff for quick and effective care. But an examination by The New York Times, including a survey of all major cruise companies, a review of court cases and interviews with current and former employees of cruise lines, shows that in other cases the results are injuries, death and striking accusations of negligence and malpractice.

Margaret DiBari, a 47-year-old nursing home inspector from Queens, complained of chest pains and difficulty breathing on her dream cruise, but the ship’s doctors said she had acute bronchitis. The day after the ship returned to New York, doctors at Lenox Hill Hospital discovered she had had a heart attack, most likely on the ship. Admitted to intensive care, she had a second attack and died.

The parents of Elizabeth Carlisle, a 14-year-old from Michigan, said she sustained lifelong health problems because a ship’s doctor failed for three days to recognize that her appendix had ruptured.

Janice Hatch, a diabetic on her honeymoon, lapsed into unconsciousness and convulsions after a ship’s nurse apparently gave her the wrong medication.

And Sharon Lum, a California kindergarten teacher, said she returned to a ship’s infirmary five minutes after a nurse said her husband was improving after severe vomiting and diarrhea, to find him dead.

Those examples are drawn from interviews and pending lawsuits, and the cruise lines dispute the accusations of negligence in each case. A review of lawsuits filed over three years against cruise lines in Miami, where most cruise tickets stipulate that actions against the companies must be filed, found that most cases were settled, with the terms kept secret.

Lawyers for the cruise companies say cases are settled to save legal costs and for other business reasons. Lawyers for passengers say the companies resolve claims to avoid appeals that would challenge their exemption from liability for their doctors’ actions on board ships.

Medical care is not perfect on land, and suits are filed regularly against leading hospitals, too. But the quality of care at sea has become a more pressing issue as the cruise industry has doubled in size over the last decade and its ships have also grown.

Three years ago, the American Medical Association brought pressure on the industry to improve care after a study by two Florida doctors, Bradley S. Feuer and Richard S. Prager, found glaring inadequacies in staff qualifications and equipment on ships.

In a survey of 11 cruise lines, the doctors found that 27 percent of doctors and nurses did not have advanced training in treating victims of heart attacks, the leading killer on ships, and 54 percent of doctors and 72 percent of nurses lacked advanced training for dealing with traumas.

Fewer than half of shipboard doctors — 45 percent — had board certification, an important credential that is granted after three to seven years of residency and a written examination in a specialty, or its equivalent. There are 24 specialty board certifications recognized by the American Medical Association and the American Board of Medical Specialties. Ideally, ship doctors would have certification or an international equivalent in emergency medicine, family practice or internal medicine.

As for equipment, the survey found that 63 percent of the ships did not have equipment for blood tests for diagnosing heart attacks, and 45 percent did not have mechanical ventilators or external pacemakers.

“What we found was that the quality of maritime medical care was less than adequate, from the medical facilities to nurse and physician credentials,” said Dr. Prager, a critical-care physician at Baptist Hospital in Miami.

The American Medical Association passed a resolution in 1996 calling for Federal legislation or an international treaty to establish minimum medical standards on all cruise ships.

A spokesman for the association, Robert J. Mills, said establishing standards remained a legislative priority. But Congress has not acted and the issue was not raised at Congressional hearings on safety in the industry earlier this month.

The absence of medical standards is one of several examples of the lack of regulation over the cruise industry.

In part to head off Federal Government controls, the cruise companies and their increasingly influential Washington trade association, the International Council of Cruise Lines, have turned to voluntary guidelines.

After articles in The Times about shipboard assaults and efforts to cover up some incidents, the industry association said in July that its members would report all suspected crimes to the proper authorities, including the Federal Bureau of Investigation.

And after Royal Caribbean Cruises pleaded guilty to criminal pollution charges and paid $27 million in fines in the last 18 months, the industry said this month that it would take voluntary steps to improve environmental controls.

The industry responded in similar voluntary fashion to the medical establishment in 1996, adopting guidelines for staffing and equipment that were written with help from the American College of Emergency Physicians, whose members sometimes serve on ships. The industry emphasizes that its guidelines are suggestions, not standards, but people within the industry and some outsiders credit them with improving care.

“Historically there has been a range of capabilities and facilities,” said Dr. Carter Hill, medical director for Holland America Line. “A lot of that was because there were no guidelines. I really feel the industry has responded in a positive way.”

The guidelines say doctors should have a medical license and competency in advanced life support or cardiac care, though certification is not required. They say doctors should have experience in general practice and also in emergency or critical care, but board certification or equivalent international certification is not required.

The industry suggests that ships carry two cardiac monitors, two portable defibrillators, an electrocardiograph, an external pacemaker, respiratory support equipment and, on new ships, X-ray machines.

Ships generally have one or two doctors and two or three nurses, depending on the number of passengers. The cruise lines serving United States ports, including Carnival, Royal Caribbean International and Princess Cruises, meet the industry guidelines, according to responses to a survey sent out by The Times.

But not all ships meet the higher standards outlined in the 1996 study that prompted the American Medical Association’s resolution, according to the survey responses from 10 of the 16 foreign-owned cruise lines operating out of United States ports.

For instance, Carnival, the world’s biggest cruise line, said 56 percent of the doctors on its 14 ships had board certification or equivalent credentials. Royal Caribbean, the second-largest line, said 85 percent of its doctors were board certified.

Among the major lines, only Princess Cruises and Holland America Line said all of their ships carried blood-transfusion equipment, according to their responses to the Times survey.

Princess and Holland America, a division of Carnival Corporation, received high marks from outside medical experts, and both exceeded the industry guidelines. Princess Cruises, for example, employs only full-time physicians licensed in Britain, which has requirements similar to those of the United States; its doctors have at least three years of postgraduate training and certification in advanced trauma life support. The line pays them $120,000 a year, more than twice the salary at most other cruise companies.

“We try and pay the amount of money required to attract well-qualified individuals,” said Dr. Alastair Smith, the medical officer of Princess Cruises.

The company’s 2,600-passenger Grand Princess has the industry’s first telemedicine system, which allows specialists at Cedars-Sinai Medical Center in Los Angeles to connect to the ship via satellite to assist the on-board doctors. All nine Princess ships carry thrombolytic drugs, the so-called clot-busting superdrugs that increase survival chances in many heart attack patients. Few other lines carry them.

Still, even the most sophisticated cruise ship is not a floating hospital. The goal in the most serious emergencies is to stabilize patients until they can be transported to hospitals on land (at passengers’ expense). Industry experts say the quality of care is comparable to what travelers would expect in any resort area.

“A ship is a small town, and people should expect to find the same medical care there that they would in any other small town of a couple thousand people,” said Dr. Theodore E. Harrison, a physician and president of a company that recruits doctors for cruise lines.

But other doctors and critics of the lines challenge that comparison. Qualifications for small-town doctors in the United States are more stringent than those for doctors on most cruise ships. And transporting a critically ill patient from a rural clinic or hospital to a more sophisticated one is far easier than evacuating someone from a ship.

Dr. Joel S. Cronin, who spent 10 years as a surgeon before becoming a maritime lawyer, said: “It may be fair to say care on a ship is like a small town, except for one thing. In the small town, they can call an ambulance and get you to a big city. It’s a lot easier, and a lot cheaper, too.”

Last Christmas, Dr. Marie Gade, a New York City radiologist, was on a cruise with her family on Cunard’s flagship Queen Elizabeth 2 when she was struck by a van during an excursion on the island of St. Thomas. Her pelvis was fractured in several places, and she and her husband, Dr. Ronald Gade, decided to avoid the island’s hospital in favor of the care offered on the ship.

But when the couple arrived at the infirmary, they discovered that there was no equipment to transfuse blood, which would have been needed if Marie Gade had had internal bleeding, and that other basic equipment was absent.

Rather than remain on the ship, Marie Gade was taken to an airport on a nearby island and flown on a medical jet back to New York, she and her husband said.

Chances of needing shipboard medical care are slim, but the American College of Emergency Physicians estimates that 4 percent to 5 percent of passengers will succumb to anything from a sprained ankle to food poisoning. That means a minimum of 200,000 medical cases this year. The group estimates that 500 of those passengers will require removal to a hospital on shore.

For those who do face emergencies on cruise ships, the primary cause of death is heart attacks. An analysis by The Times of the 60 reported natural deaths aboard cruise ships sailing out of Miami from 1996 through mid-September of this year found that more than 90 percent were caused by heart attacks or heart-related problems.

Some victims were elderly or had a history of heart disease or both, but some were younger and had shown no symptoms.

Margaret DiBari had no history of heart problems when she boarded Celebrity’s Zenith for a cruise from New York to Bermuda on June 28, 1997. Two days later, she went to the infirmary complaining of difficulty breathing and chest pain. One doctor, German Leon, took a chest X-ray and diagnosed an upper respiratory tract infection and acute bronchitis, according to deposition testimony in the suit brought by her mother against Celebrity Cruises and two doctors in Federal District Court in Manhattan.

Over the next three days, Ms. DiBari’s condition did not improve, and she returned regularly to the infirmary, where she was treated by Dr. Leon and a colleague, Dr. Juan Sarmiento, both natives of Colombia and graduates of medical schools there. Her condition did not improve. The day after the ship returned to New York, she was hospitalized, and she died in intensive care.

Dr. Richard P. Friedlander, a cardiologist hired by Ms. DiBari’s mother, wrote in a report prepared for her lawyer, Alan L. Fuchsberg, that the shipboard doctors had failed to detect evidence of a heart problem on the X-ray. He wrote that the failure to treat Ms. DiBari properly and to refer her urgently to a hospital “more likely than not” increased the risk of her second, fatal heart attack.

In a deposition, Dr. Sarmiento said he had not looked at the X-ray as part of his examination of Ms. DiBari. While examining the X-ray during questioning, he said it could indicate a heart ailment but was also consistent with other problems. Lawyers for the cruise line and the two doctors maintained in court filings that Ms. DiBari was treated properly and that her death was not related to what occurred on the ship.

A Celebrity spokeswoman said the company would not comment, and lawyers for Dr. Leon and Dr. Sarmiento did not return phone calls.

Dr. Sarmiento’s deposition and documents produced in the court case shed light on the hiring and pay practices at Celebrity Cruises, which is part of Royal Caribbean. Neither doctor was licensed to practice in the United States or had advanced training in cardiac care. They were paid $2,300 a month in cash by the ship’s purser. In addition, they received 9 percent of the fees charged passengers for treatment, and free accommodations. Neither carried malpractice insurance.

Dr. Carlos Gonzalez, a former ship’s doctor, is a medical consultant to Celebrity responsible for evaluating doctors applying to work on ships. In a deposition, he said most applicants were not board certified, but he said that did not mean they were unqualified.

Doctors trained in some developing countries, Dr. Gonzalez said, use the shipboard jobs “as a step to coming into the States.”

Dr. Gonzalez said he had interviewed Dr. Sarmiento after a former colleague introduced them, but he said he had no recollection of contacting any of his references. According to court records, the resume submitted by Dr. Sarmiento did not list references.

In its response to the Times survey, Celebrity declined to say what percentage of its doctors were licensed in the United States. It said only that its shipboard doctors held valid medical licenses in their respective countries, which is consistent with the industry’s guidelines. Half of its doctors hold board certifications or an international equivalent, the company said.

A doctor who was not licensed in the United States also saw Elizabeth Carlisle when she became ill on Carnival’s 2,000-passenger Ecstasy in March 1997. Shortly before boarding the ship with her parents, the teen-ager felt mildly ill. Her mother, Darcy Carlisle, telephoned Elizabeth’s pediatrician at home in Ann Arbor, Mich. He suggested they check with the ship’s doctor.

Not far out of Miami, her parents took Elizabeth to the infirmary, where Dr. Mauro Neri saw her. Without examining her, he said her symptoms sounded like flu and prescribed an antibiotic, according to the complaint filed by the family against Carnival in Dade County Circuit Court in Miami. The next day, nauseated and in pain, she returned to the infirmary and Dr. Neri prescribed a different antibiotic, the complaint said.

By the third day, the symptoms had grown worse, and the Carlisles faxed the details to her pediatrician. He urged them to return home immediately. Before the Ecstasy docked in Cozumel, Mexico, Mrs. Carlisle took Elizabeth back to Dr. Neri. At Mrs. Carlisle’s insistence, he examined her physically for the first time, according to the suit.

“I asked him point blank if this could be appendicitis,” Mrs. Carlisle said in an interview. “He said, ‘No, no, it’s not. I’m not sure what it is. I’m sorry your vacation has been ruined.’ ”

In Michigan, doctors discovered that Elizabeth’s appendix had ruptured and she had a massive infection. She underwent two operations and has what are expected to be lifelong health problems, according to the complaint.

The complaint accuses Carnival of employing doctors who were poorly educated, not licensed in the United States and not skilled in handling emergencies. It also accuses the company of false advertising for saying there was a competent doctor on board.

Charles R. Lipcon, the Miami lawyer who filed the suit, said, “In every suit I file against cruise companies, I claim bad medical care because invariably there is bad medical care.”

Carnival’s lawyers said the company was not responsible for the care provided by Dr. Neri. “It is well settled that a cruise ship operator cannot be held vicariously liable for the negligence of its ship’s medical staff in the care and treatment of passengers,” they said in a court filing, citing several cases in which judges ruled in cruise lines’ favor.

Carnival and other cruise lines say they are not responsible for the doctors and nurses on their ships because they are independent contractors, not employees. They also say that maritime law requires them to provide medical care only for the crew, not passengers.

Lawyers for passengers counter that the doctors are agents of the ship’s owner because they wear an officer’s uniform, have their office on the ship and are paid by the ship. Passengers, they say, are essentially captives unable to seek other medical care. The courts, however, have sided with the industry.

Dr. Neri has not responded to the Carlisle suit, and efforts to locate him were unsuccessful. According to court records, Dr. Neri finished medical school in his native Italy in 1981 and had nine medical jobs in Italy, Africa and England before he was hired by Carnival in 1996 for $1,057 a month. His last job had been at a hospital in Middlesex, England.

Dr. Arthur Diskin, chairman of the emergency department at Mount Sinai Medical Center in Miami Beach, is Carnival’s medical hiring consultant. He said he had relied on Dr. Neri’s resume in recommending hiring him and made no independent effort at verification.

“Knowing the British system, I would have relied a lot upon his most recent employment being in Britain,” he said in a deposition in the family’s suit.

Doctors applying to a small-town hospital, by contrast, usually have their license and medical-school record examined by a credentials committee. Representatives of the committee also talk directly to those named as a doctor’s references, and the applicant must appear for an interview.

Graduates of foreign medical schools must pass a series of tests to apply for a license in this country. New York City’s public hospitals rely heavily on foreign-trained doctors, but their minimum standards require that the doctor complete a residency and pass a foreign medical exam and the state licensing exam.

The point, said Dr. Jane Zimmerman of the city’s Health and Hospitals Corporation, is not that foreign-trained doctors are not as good as their American counterparts but that they must meet the same basic qualifications.

Carnival officials declined a request for an interview. In response to written questions, the company said the credentials and references of its doctors and nurses were verified by telephone or in writing. The company also said that its staff and infirmaries met the industry’s guidelines and that its doctors had malpractice insurance.

People rarely consider medical care when planning a cruise. They are more likely to think about the size of their cabin, the quality of the food and the ports of call. Often, ship’s doctors said, passengers even forget to bring their medications.

Irma Curtis, a real estate agent from Cockeysville, Md., wanted to leave nothing to chance when she and her husband, James, headed off on a weeklong cruise in February aboard Carnival’s Sensation.

“Because Jimmy had had heart surgery a year earlier, I insisted that he get a complete physical before we went,” she said in an interview. “I wanted to make sure we weren’t going to be in the middle of nowhere and have something happen. The doctors said he was absolutely fine, 100 percent fine.”

Four days after setting sail from Tampa, Fla., after an afternoon on a Mexican beach and a relaxing night with friends, Mr. Curtis lay dying in the Sensation’s infirmary.

“James Curtis slowly and painfully bled to death through a ruptured abdominal aortic aneurysm,” according to the complaint filed by his wife against Carnival Corporation, Dr. James R. Otworth and Constance Jackson, a nurse.

The complaint said that Dr. Otworth and Ms. Jackson had failed to diagnose Mr. Curtis’s condition and had not provided proper treatment, including a blood transfusion.

Instead of blood, Mr. Curtis was given so much intravenous solution that his corpse was bloated, his wife said in an interview. Sitting in her house outside Baltimore, surrounded by mementos of 30 years of marriage, she said she did not sue Carnival just for money.

“What good is money now?” she said. “I want to make an issue of the substandard care aboard cruise ships.”

It is not clear that different care could have saved Mr. Curtis. His wife’s lawyer, Michael A. Mullen, said medical experts were reviewing the case. A Carnival lawyer, Jeffrey B. Maltzman, said the rupture that killed Mr. Curtis was extremely difficult to diagnose and required immediate surgery at a major trauma center. He said the condition was usually fatal.

Mr. Maltzman said that the captain had begun to divert the ship and had notified the Coast Guard but that Mr. Curtis died before arriving in port. He also said Dr. Otworth was an American physician who was board certified in internal medicine as well as in advanced cardiac and trauma care.

Dr. Otworth and Ms. Jackson have not responded in court, and efforts to reach them were unsuccessful.

Ms. Jackson also provided care for Janice Hatch aboard the Sensation in 1997. Mrs. Hatch, a diabetic from Flint, Mich., and her husband, Craig, were on their honeymoon when she felt flushed on a walk in port and went to the ship’s infirmary upon returning.

There, Ms. Jackson and Dr. Leon Rand, a semiretired physician from New Jersey, checked Mrs. Hatch’s blood sugar with a glucose meter. According to the couple’s lawsuit, filed against Carnival in Dade County Circuit Court, Ms. Jackson said the blood sugar was extremely high and administered fast-acting insulin to bring it down.

“Instead of getting better, she got worse and worse,” Mr. Hatch said in an interview. “She was totally unconscious and went into a diabetic coma and was wringing wet. I called for the nurse, and she said she’d come around. I waited and she started jerking real bad.”

Mr. Hatch said he raced to the couple’s cabin to grab his wife’s glucose meter and returned to the infirmary. When he measured her blood sugar, he discovered that it was not too high but too low. Ms. Jackson administered glucose, and Mrs. Hatch regained consciousness after about 15 minutes.

Reports by doctors hired by the Hatches in the court files indicate that brain damage and other injuries from the episode have left Mrs. Hatch disoriented and unable to return to her job as a millwright for General Motors.

Carnival’s lawyers have challenged the suit on several grounds, including that cruise lines are not required to provide medical care. They said that the ship’s glucose meter had been checked for accuracy the day before the incident and that infirmary records showed only that Mrs. Hatch received both insulin and glucose and left the ship without complaining.

“We are very confident of our position and believe the final outcome will vindicate Carnival from any wrongdoing,” a statement from the cruise line said.

Mr. Hatch said in the interview that they had been too frightened to seek further care. “I wouldn’t have asked them for an aspirin,” he said. “Why would I? I’m the one that saved her.”

Dr. Rand and Ms. Jackson were named in a separate suit, and their lawyer, Christopher E. Knight, said neither he nor his clients had any comment. But Mr. Knight, who often represents doctors and nurses from the cruise industry, said shipboard treatment met the basic standard for care.

“What a passenger should expect and will find is reasonable emergency medical care,” he said. “What a cruise ship does not have is a full medical staff like a hospital.”

While the Federal Government does not monitor medical care on cruise ships, it does inspect them for sanitation, and there is evidence that the regulation helps. Government officials said food and water sanitation had improved significantly in recent years, and large outbreaks of gastrointestinal illness have declined.

Twice a year the Centers for Disease Control and Prevention’s Vessel Sanitation Program inspects cruise ships that use American ports. Inspectors with a 42-item checklist examine sanitation and general cleanliness. Vessels that fail to score at least 86 out of 100 are inspected again within 60 days.

If a ship fails a second time, the agency can recommend that it not sail, a step taken only once in the last three years with a large cruise ship. In the most serious instances, the Centers for Disease Control can ask the Coast Guard to invoke quarantine laws and detain a ship. Officials said that had never occurred.

“We find that the commitment to sanitation by the cruise lines is very strong,” said David L. Forney, acting director of the sanitation program, “because they realize the consequences of having an outbreak on a ship and because they realize the power of our scores from a public-relations standpoint.”

Each ship’s scores, called green sheets, are posted on the agency’s Internet site ( within a week and are distributed regularly to about 6,000 travel agents and frequent passengers.

The number of reported outbreaks of illness affecting 3 percent or more of passengers or crew members has declined to 10 in 1997 and 9 in 1998 from an average of 15 a year a decade ago, according to the agency. There has been one so far this year

Mr. Forney said the program held cruise ships to a higher standard of cleanliness than restaurants on land because an outbreak at sea was potentially so serious. “The consequences of something happening, you don’t even want to think about it,” he said.

In June 1998, at least 270 people became ill with vomiting and diarrhea from gastroenteritis on Princess Cruises’ Regal Princess over three consecutive cruises. The previous year, 354 passengers and crew members became ill in an outbreak of gastroenteritis aboard the Royal Odyssey, a Norwegian Cruise Line vessel.

An outbreak aboard Carnival’s Jubilee in June 1996 was smaller, but deadly.

Among the passengers on that cruise were Russell Lum, 52, an aircraft mechanic from Berkeley, Calif.; his wife, Sharon; their daughter, Courtney, and a niece, Robin Tom. They had boarded the Jubilee on Father’s Day in San Pedro, Calif., for a weeklong cruise along the coast of Mexico.

According to the complaint in a wrongful-death suit filed by Mrs. Lum against Carnival in Federal District Court in Miami, on the second night Mr. Lum complained that he was not feeling well. He vomited and spent the next day resting in the cabin. His wife, meanwhile, heard other passengers discussing people falling ill with diarrhea and vomiting.

At 1:30 A.M. on the third day, Mrs. Lum said in an interview, she woke when her husband collapsed outside the cabin’s bathroom. She said she called the ship’s infirmary but the nurse tried to discourage her from bringing him there because it was so late. Mrs. Lum said she insisted, and her husband was put on an intravenous solution to avoid dehydration.

After a time, the nurse took Mr. Lum’s blood pressure and said he was improving and could return to his cabin. Tired but relieved, Mrs. Lum hurried to the cabin to get towels and a change of clothes, because her husband had soiled his pants.

“My daughter and niece were awake, and I told them he was fine and would be coming back,” Mrs. Lum said. “I was gone about five minutes, and when I got back to the infirmary the doctor and nurse asked me to wait in the waiting room.”

Sobbing briefly, Mrs. Lum said she waited for several minutes, wondering what was going on. Then the doctor and nurse returned.

“They came back and told me that he had taken a turn for the worse and he had died,” she said. “I asked them how that was possible, and they said there was nothing they could do.”

Mr. Lum was the only person to die among the 52 passengers and 16 crew members who came down with viral gastroenteritis on the cruise. His death was caused by extensive blood loss from a tear in his esophagus caused by vomiting, according to the family’s complaint.

“Mr. Lum died of retching to death,” said Erik Peterson, the family’s lawyer.

Curtis J. Mase, a lawyer for Carnival, said in court papers that the company was not responsible, contending that the death was an act of God and that Mr. Lum had failed to seek timely or appropriate medical care.

“Russell Lum’s own negligence contributed to his death and injuries,” Mr. Mase said.