A state investigation found that faulty practices at a Los Angeles hospital caused a patient to bleed to death hours after giving birth via cesarean section.
California Hospital Medical Center in downtown LA saw no signs the patient had internal bleeding, which the California Department of Health and Human Services said led the woman to return to the operating room four hours after those signs appeared.
According to the state report, the patient, who was at high risk of bleeding, died on the same day in March as her caesarean. An autopsy revealed the cause of death was hemorrhagic shock — severe blood loss that led to insufficient oxygenation of cells — along with an impaired ability of the blood to clot and stop bleeding, the report said.
State investigators described the hospital as “imminently at risk,” meaning failure to comply has resulted in, or is likely to result in, serious harm or death. The tag was removed after the California Hospital Medical Center unveiled a plan to retrain staff in the labor and delivery departments to identify and treat bleeding, it said condition report about his knowledge.
“I would like to express my deepest condolences to the family for their unimaginable loss,” hospital president Alina Moran said in a statement. “When there is an unexpected outcome in patient care, we conduct a review of the care provided and work to identify opportunities for improvement.”
“As part of our process, we have met with the family and shared the changes we have made and are making to prevent similar incidents. … The safety of our patients remains our top priority,” Moran said.
The hospital did not incur any financial penalties as a result of the findings, a spokesman said.
In its report, the Department of Health identified the hospital with more than a dozen deficiencies or failure to meet conditions under federal hospital reimbursement programs. In some cases, the state agency specifically stated that improper practices had resulted in the patient’s death.
For example, hospitals are supposed to maintain an ongoing program to improve their performance, but the state team found they had failed to properly maintain those efforts. Hospital staff told the state that California Hospital Medical Center failed to follow its own procedures for treating obstetric hemorrhage.
“This poor practice led to this [the patient’s] Death four hours after cesarean delivery,” concluded the country team.
State investigators also noted that there was a one-and-a-half hour delay before the patient received a second red blood cell transfusion. And the hospital failed to notify its governing bodies about the patient who bled, hampering its ability to push for improvements, the state noted.
The state team also found other issues with other patients at California Hospital Medical Center during its April review, including a failure to take steps to prevent potentially fatal blood clots from developing in patients.
Founded more than a century ago, the LA hospital is now part of Dignity Health, one of the largest healthcare systems in the country. The California Department of Health has released additional findings about the facility over the past year and a half: Last summerA sponge was left in the vagina of an endometrial cancer patient being prepared for surgery and was not removed until the next day, in violation of hospital policy, sources said.
Earlier this year, state investigators accused another Southern California hospital — Centinela Hospital Medical Center in Inglewood — of failings that could put patients in its labor and delivery unit at risk. The findings have been followed by public protests and calls for an inquest into the death of April Valentine, a 31-year-old woman who gave birth at Centinela Hospital. Black women like Valentine are at higher risk of dying from pregnancy complications than other women in California.
And the Times reported this week that Cedars-Sinai Medical Center is facing a federal civil rights investigation over the treatment of black women who give birth there. The investigation stems from allegations of discrimination following the death of Kira Dixon Johnson, who died after going to Cedars-Sinai to give birth to their second son.
The state report did not name the patient, who died after the caesarean section at California Hospital Medical Center.