Paramedics were making so many trips to a dialysis clinic in the East Texas city of Lufkin, a top fire department official wrote an anonymous letter to state health department inspectors pleading for somebody to take a look at the place.

“In the last two weeks, we have transported 16 patients,” the mid-April 2008 note said. “This seems a little abnormal and disturbing to my med crews. Could these calls be investigated by you?”

State medical surveyors within days showed up at the DaVita Dialysis clinic in the Texas Piney Woods community about 125 miles northeast of Houston. By then, EMS had been called as many as 30 times that month, including seven for cardiac problems, and made at least 19 runs. Four people had died. Over the previous 15 months, there had been two calls,