Backstory: Infant death during birth prompts state investigation at Cooley Dickinson Hospital, Northampton

Sunday, March 16, 2014
NORTHAMPTON — The president of Cooley Dickinson Hospital’s medical staff Thursday called the death of an infant at its Childbirth Center unusual and pledged to take “very seriously” the findings and recommendations of state regulators investigating the case. The hospital announced Thursday that the infant’s death may have been the result of “fragmented communication” among staff in the decision-making process during childbirth.

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According to a three-page letter to hospital staff released Thursday, investigators with the state Department of Public Health were at the hospital recently to conduct a multi-day review of the death, referred to in the statement as a stillbirth.

Letter to Cooley Dickinson staff regarding stillbirth

The DPH report is expected to be issued soon and hospital officials said they already are using the state agency’s initial feedback “to inform and guide our efforts.” “This is not a common occurrence at this hospital and we really wanted to be open and honest about the event and really ensure the community that Cooley Dickinson is a really safe hospital,” Dr. Margaret A. Russo, president of CDH’s medical staff, said Thursday. “If there is something to be learned from this event, we intend to learn every possible thing we can.”The DPH confirmed Thursday that it is conducting an investigation of “an infant death reported by CDH,” which is standard protocol in serious reportable events. The state agency declined to release any more information. “DPH is aware that the hospital has conducted its own review and has begun taking action to ensure that its patients receive safe and appropriate care,” spokeswoman Anne Roach wrote to the Gazette. Hospital officials declined to answer questions about how the baby died or be more precise about what may have gone wrong, citing the federal law that protects patient privacy.However, officials said by providing as much information as it can about the events, the hospital is counting on its staff to help prevent misinformation from damaging the public’s confidence and trust in the hospital. “We really want to be sure that everyone knows how we respond to the events, and we believe it’s our responsibility to do the right thing,” Russo said.The hospital’s statement to staff does not say when the death at its Childbirth Center occurred, or where the family involved is from. The memo came from Matthew Pitoniak, the hospital’s acting president, and Dr. Mark Novotny, its chief medical officer, with the intention of letting all staff know how the hospital is responding to the event, said Christina Trinchero, a hospital spokeswoman. The statement makes reference to the family involved. “Our hearts go out to the parents of the baby who died and other family members as they grieve and try to come to grips with their loss,” it reads. “We reached out to the family to apologize for their loss and to express our deepest sympathies. We also let them know we want to do what we can to support them.” The statement says the impact on the Childbirth Center’s staff has been “profound” and they also are grieving. “In the wake of the events, our doctors, midwives, and nurses are working to implement every reasonable and feasible action for the safety and well-being of mothers and newborns,” the memo to staff states. The hospital launched its own inquiry. Hospital officials do not believe the death was related to staffing levels, stating that the Childbirth Center appeared properly staffed with capable, experienced clinicians. Asked whether the “fragmented communication” the hospital had anything to do with staffing shift changes at the Childbirth Center, Russo said, “I don’t believe that it did.” The letter to staff also states, “In addition to learning that communication among the providers involved in the stillbirth could have been better, we also recognize that even though certain complications of pregnancy may be extremely rare, staff members must be attuned to unusual symptoms and indicators that signal uncommon events and be fully prepared to respond.”The hospital outlined eight steps it has taken to improve quality and safety systems and put in place additional measures with the help of various outside experts, including a team from Massachusetts General Hospital and Dr. Benjamin Sachs, former chairman of obstetrics at Beth Israel Deaconess Medical Center, who reviewed CDH’s Childbirth Center. The hospital says it has taken the following new measures: ∎ twice-daily patient safety consultations involving every team member to review the care of all current obstetric patients to identify as early as possible any potential complication or risk; ∎ twice-weekly meetings of senior administrative and medical staff leaders, including the hospital’s acting president and chief medical officer, to monitor the implementation of safety-related action plans; ∎ organization-wide communication about the hospital’s 24-hour safety hotline. Some of the experts called in have reviewed the events that prompted the DPH investigation as well as other difficult cases that presented various types of complexities and risks, according to CDH. Hospital officials said they paid particularly close attention to decisions and processes related to cesarean sections, vaginal birth following cesarean, forceps deliveries and other situations that involve specific interventions. “The cases reviewed were all quite different, most involving uncommon but well-known risks of pregnancy and childbirth,” the memo from Pitoniak and Novotny states. “However, we did find areas for improvement that may be included in the DPH report.” Between October and December 2013, four obstetrical providers left Cooley Dickinson to pursue other opportunities, while another went on maternity leave during that period, according to the hospital, which is actively recruiting obstetrical providers to bring its staff numbers back up. A new obstetrician and a certified nurse-midwife have recently been hired and will join the medical staff in April, while two temporary obstetricians continue to work alongside staff at the Childbirth Center, according to the hospital. Dan Crowley can be reached at dcrowley@gazettenet.com.