DPH report reveals details of six cases under review

Last modified: Friday, April 25, 2014

NORTHAMPTON — Details of six incidents over the last two years that the state is investigating at Cooley Dickinson Hospital’s Childbirth Center — including three that resulted in the deaths of a mother and two babies — are included in a state report posted Friday on the hospital website.

The report by the state Department of Public Health on behalf of the Centers for Medicare and Medical Services, does not include personal information about the patients or the dates of the incidents at the birthing center, due to health privacy laws.

But it provides information about how the three patients died and findings on how the hospital failed to provide quality care and oversight in those cases.

“The failure to provide quality medical care resulted in the death of all three patients,” the DPH report states.

Anne Roach, spokeswoman for the Massachusetts Department of Public Health, said via email Friday that the DPH investigation of the hospital is “ongoing” and that the complete report is not yet available.

Dr. Mark Novotny, Cooley Dickinson’s chief medical officer, said in an interview Friday that a “vigorous internal investigation” by the hospital agreed with the broad outlines of the state report.

“The themes and processes by and large overlap with ours,” he said, though he added that the hospital does not agree with all of the conclusions in the DPH report.

Novotny said Cooley Dickinson has completely reorganized how care is provided in the Childbirth Center in the wake of the incidents covered in the report — the most recent of which occurred in March.

The report on the hospital’s website describes the fatal incidents as follows:

∎ Patient #1, a pregnant woman, was admitted with complaints of abdominal pain and vomiting, the report states. Nurse notes indicated she became “increasingly confused” on the ride to the hospital. Within 10 minutes after arriving in the Childbirth Center, the patient’s blood pressure was 179/144, compared to a normal range of 90-120/60-80, according to the report. The patient was intubated and taken to the operating room for delivery by cesarean section.

The report states the patient was given Magnesium Sulfate, used to treat pre-eclampsia, a life-threatening complication of late pregnancy that includes symptoms of headache, dizziness, vomiting and abdominal pain — among other symptoms. The report states she “did not receive treatment for her high blood pressure.”

The woman was unconscious after delivery, transferred to the intensive care unit, and once stabilized, a CAT scan revealed she’d had a stroke. Hospital staff tried to have her transferred to “Hospital B,” identified in the report only as being located 18 miles from Northampton.

But “systems issues did not allow the transfer,” the report states. She was then “transferred via helicopter to Hospital C, where she died,” according to the report. It describes “Hospital C” as located approximately 118 miles from Northampton.

∎ In the second incident, Patient #2 became “stuck in the birth canal and unable to be removed by cesarean section delivery and died,” according to the report. It states that the hospital “failed to ensure that Patient #2’s mother’s variation in pelvic anatomy was communicated early in the labor process,” which led to a “prolonged pushing phase.” Though doctors performed a C-section, the baby “was too tightly wedged in the pelvis and died during attempts to extricate,” according to the report.

∎ The third fatal incident involved a baby delivered without a heart beat who could not be revived through neonatal resuscitation, according to the report.

Labor and delivery notes said the baby had an “abnormal heartbeat pattern indicating increased risk for death for the baby for 10 minutes in the last 30 minutes of fetal monitoring,” the report states.

The notes “did not indicate an explanation, evaluation or interventions” by either the registered nurse, or the certified nurse midwife.


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