Friday, May 23, 2014
NORTHAMPTON — Cooley Dickinson Hospital’s chilling public admittance that lack of training and poor communications among staff in its Childbirth Center may have led to the maternal death of a mother and two babies in three separate incidents falls woefully short of an acceptable public apology involving an issue that dates back to another maternal death case at the hospital on May 27, 2007.
This is the first public account outside of court records of the pain and suffering Heather Egan Haynes felt, fully conscious, before the morning of her untimely death in 2007. Unlike the recent cases in which the hospital publicly admits mistakes were made, after Haynes’ death no mistakes were admitted. Hopefully, this account will answer lingering questions Haynes’ friends were left to wonder about concerning her death at Cooley Dickinson.
Haynes’ nine-pound son was four days old when he left his Haydenville home swaddled in a blanket and carried by his father to come live with my family in Amherst. His mother was a dear friend. We grew up in the same neighborhood in Philadelphia and she worked as a personal care attendant for my severely disabled daughter for many years. My wife and I naturally wanted to help.
The cases described by Cooley Dickinson authorities in its public admission were sentinel events, which “is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, according to the Joint Commission, an independent, not-for-profit organization that accredits and certifies more than 20,000 health care organizations and programs in the United States.
Since the mid-1950s maternal deaths in the U.S. have been made largely preventable through public health awareness, pre-natal care outreach and a body of medical knowledge on treating common and severe pregnancy-related complications that can lead to death like gestational diabetes, preeclampsia and hemorrhage.
“Maternal mortality is one of the most important indicators of population health and the quality of health care in a society,” according to a 2011 report issued by the California Pregnancy-Associated Mortality Review.
The fact that two women have died in the last seven years while giving birth or seeking emergency postpartum care at CDH should have raised alarms throughout the Northampton community.
Why did those alarms fail to go off inside and outside the hospital to alert the community? That’s the question I asked myself as I picketed outside the hospital for many months in 2009, carrying a sign that read “Pregnancy-Related Deaths Are Preventable.”
This was also the theme of the Heather Egan Haynes Memorial Lecture I organized at Forbes Library in October 2009. The lecture brought together Susan A. DeJoy, chief of midwifery at Baystate Medical Center, and Samantha R. Lattof, a former project manager for the Maternal Health Task Force at the Harvard School of Public Health, to provide local, national and international perspectives on the issues of maternal health and mortality. In addition a documentary, “No Woman, No Cry,” by Every Mother Counts, was also featured.
Those alarms about care at the hospital should have come from doctors, nurses, midwives, obstetrical and gynecological service providers, community news organizations, home health care concerns, private physician practices — all operating in the CDH universe of care.
In December 2010, the Medical Malpractice Tribunal in Massachusetts, having reviewed the Haynes case, found “substantial sufficient evidence to raise a legitimate question of liability appropriate for judicial inquiry.”
In the Haynes case, the Estate of Heather Egan Haynes and the 14 defendants identified in the medical malpractice case settled the matter out of court late last fall shortly before the case was scheduled to go to trial, some six years after her death.
Haynes’ maternal death is not one of the cases that caused CDH to admit its systemic failures this year, but one has to wonder what effect the six most recent incidents and the continued open review by the Massachusetts Department of Public Health had on the outcome of the Haynes case.
According to Cooley Dickinson’s account of the sentinel events that have taken place, the new management and Board of Trustees should be credited with reporting the incidents.
The fact that Haynes’ maternal death case was not mentioned is probably a result of the recent settlement between the parties.
If CDH seeks to be transparent on the issues of maternal death and infant mortality, why did it take six years to settle the Haynes case? And why did it take one to two years after the most recent incidents in its Childbirth Center to admit that the sentinel events that had taken place were more than the patient’s condition that caused the complications?
How long after 2007 did CDH’s management know that its standard of postpartum care deviated from accepted standards elsewhere?
The day she died
Haynes was transferred by ambulance early May 27, 2007, from her home in Haydenville to Cooley Dickinson, three days after she gave birth at another area hospital. She instructed her husband to stay home with their new baby as ambulance personnel whisked her away. She sought medical attention for postpartum complications caused by excessive bleeding. She thought she would go to the hospital, get checked out and return home later in the day.
In the CDH Emergency Department, and over the course of the next five hours, her care was transferred among three doctors and two exam rooms before she was finally rushed into the operating room.
Without a trial, we’ll never know the answers to the dispute in the Hampshire Superior Court records whether the doctors who responded to Haynes’ request for emergency care at CDH were negligent. Dr. Jeffrey Phelan, one of the doctors who reviewed the case for the plaintiff, found that one of them had “failed to timely evaluate and recognize the clinical significance of her postpartum hemorrhage, and to timely initiate medical and surgical therapy to correct Heather Haynes postpartum hemorrhage.”
She was given an IV, administered oxygen, and matched for blood type. At around 5:20 a.m., some two hours after arriving at the hospital, Haynes’ skin was still pale, bleeding increased after slowing earlier and she was moving side to side for comfort, according to Hampshire Superior Court records. After signing consent papers for a blood transfusion, Haynes’ first unit of packed cells was started.
Shortly before her care was transferred to a third doctor, the on-call obstetrician, at around 5:40 a.m., Haynes was asked to sign another consent form, this one authorizing a surgical procedure known as D&C, for dilation and curettage.
Over the next 30 minutes Haynes’ blood pressure plummeted. She exhibited increased anxiety and restlessness. At or around 6:40 a.m., an emergency “stat page” was broadcast, paging back the on-call obstetrician to return to the ER, a point that was later raised in the court records concerning the whereabouts of the obstetrician.
Haynes was asked to sign yet another consent form, this time for anesthesia. Less than 10 minutes later Haynes was in the operating room in critical condition. Two calls were made from the operating room to general surgeon service in a scramble for help from more senior surgeons at 7:29 and 8:14 a.m. Around 8:20 a.m. a code blue was called and cardiopulmonary resuscitation was started. Efforts to save Haynes’ life failed and surgery ended about 8:28 a.m. She was pronounced dead at 9:14 a.m.
An autopsy conducted May 30 listed the cause of her death as disseminated intravascular coagulation due to postpartum hemorrhage. She was 38.
A Massachusetts Department of Health review looking into her death would later reveal that if current standards were followed an inexpensive blood test could have given the doctors the answers to her condition and they would have known more aggressive treatment was needed.
For months after her death friends whispered about the cause of it, wondering what happened at the hospital and why they couldn’t save her. After Haynes’ death, the Rev. Peter Ives, then presiding minister of First Churches of Northampton, where Haynes was married, called her death a tragedy that defied simple explanation.
“All of us are saying, ‘My God, my God, why did this happen? All we can do is hold each other and remember her life and what a gift it was to us all,” Ives said.
Two years later outside of Cooley Dickinson, I paced a sidewalk outside holding a sign that said “Pregnancy-Related Deaths Are Preventable.”
I still believe that more strongly than ever and I challenge the hospital administrators and staff to work to make this true by collaborating with area educational institutions and holding an annual maternal health lecture series for the public in honor of the late Heather Egan Haynes.
Ken Johnston lives in Northampton.