Investigators find hospital error caused mother's death in Brooklyn

New York State Department of Health investigators have concluded that a disturbing error by a surgical team at a Brooklyn hospital resulted in the recent death of a 30-year-old mother who gave birth by cesarean section, according to a document obtained by The New York Times.

It is the second known case in recent years in which state health authorities have blamed doctors for a maternal death at Woodhull Medical Center, long considered one of the weaker hospitals in the city's large public hospital system.

The death of the woman, Christine Fields, in November brought renewed attention to the racial disparities surrounding childbirth in New York City. Mrs. Fields was black. In New York City, black women are nine times more likely to die during childbirth than white women. That disparity is far greater than that seen nationally, and a range of officials, from Mayor Eric Adams to Governor Kathy Hochul, have sought ways to reduce it.

Few details are known about the cause of Mrs. Fields' death. She was in labor in Woodhull when a change in the fetus's heart rate caused alarm. Doctors decided that an emergency caesarean section was necessary.

According to the medical examiner's office, Mrs. Fields bled to death in the hours after her son was delivered. But Woodhull has not yet given the family an explanation as to why it was so slow to discover Ms. Fields' deteriorating condition, according to her fiancé, Jose Perez.

A two-page document from the state Health Department obtained by The New York Times sheds some light on what happened. The document, dated Dec. 18, describes how an accident near Woodhull resulted in a maternal death and violated federal health standards.

The document does not mention Ms. Fields by name. But a doctor in Woodhull said it clearly referred to Mrs Fields' death. The details were consistent, said the doctor, who insisted on anonymity because the doctor was not authorized to discuss the case. Furthermore, the date of the document is only five weeks after Mrs. Fields' death.

The document explicitly states that an error by medical staff members “led to her death.” It describes a disturbing communication breakdown where the surgical team – a reference to the staff members who performed the caesarean section – failed to warn others of complications arising during the operation. The most serious of these was a “uterine arterial injury,” state Health Department investigators concluded, according to the report.

That injury was also not mentioned in the initial medical records regarding the cesarean section.

Mr. Perez recalled that Ms. Fields deteriorated rapidly after being sent to a recovery room after the procedure. He kept trying to talk to her, but got little response. He looked for ice cream to put on her lips. He found a nurse and told her something was very wrong; Ms. Fields' head had slumped to one side, Mr. Perez recalled. Soon, medical staff members performed CPR on her.

The medical providers who cared for Ms. Fields did not quickly notice her complications, Mr. Perez said, and seemed surprised when she became less responsive.

The lack of documentation and communication about the uterine arterial injury “resulted in maternal deaths,” the report concluded.

“This should not happen to anyone in this city,” said an attorney for the family, Sanford Rubenstein.

The document does not provide a detailed account of the caesarean section, the complications that arose or what care Mrs Fields received afterwards. Rather, it contains the initial findings of Department of Health investigators, who carried out an inspection of the labor and delivery floor in Woodhull. It specifically targets violations of safety and health regulations, such as the requirement that surgical complications be recorded in a report immediately after a procedure.

A spokesman for the city's public hospital system, Chris Miller, declined to answer questions about Ms. Fields' death, citing privacy laws. “Woodhull has updated and improved its protocols in its obstetrics and anesthesiology departments, and has recently hired two new clinical leaders in these areas,” he said in a statement.

The circumstances of Ms. Fields' death so alarmed health inspectors that they required some Woodhull employees to revise certain hospital policies or receive training so the labor and delivery unit could remain open, according to two hospital employees briefed on the matter. were brought up from what had happened. happened to Ms Fields, but who wished to remain anonymous as they were not authorized to discuss the matter.

“There is a need for immediate action for patients undergoing procedures to prevent serious adverse outcomes,” the Department of Health told Woodhull's top executive, the document said.

The Department of Health's investigation into the labor and delivery floor is not yet complete. The two Woodhull employees said investigators were looking into several other cases.

A Department of Health spokeswoman said that due to the severity of investigators' initial findings, they had suspended their wider inspection to work with the hospital on a corrective plan.

“Once the urgency for patient harm is resolved, the investigation team will resume the remainder of the investigation,” spokeswoman Danielle De Souza said.

Although Woodhull is a public hospital, its physicians are largely staffed by NYU Langone Health, an agreement the public hospital system has with a number of university health care systems. A spokesman for NYU Langone, Steve Ritea, said it had fired the doctor who performed the C-section on Ms. Fields.

Mrs Fields is not the first mother to die during childbirth in Woodhull due to doctor error. In 2020, a 26-year-old first-time mother, Sha-Asia Semple, stopped breathing after a failed epidural. In addition to misplacing the epidural, the anesthesiologist inserted a breathing tube into Ms Semple's esophagus instead of her trachea, the Department of Health concluded. Instead of delivering oxygen to her lungs, the ventilator pumped air into her stomach.

The anesthetist responsible, Dr Dmitry Shelchkov, had a disturbing record even before Ms Semple died in July 2020. Dr. Shelchkov was subsequently stripped of his medical license in New York and he moved back to Russia, where he had grown up.

There are typically between 20 and 30 maternal deaths annually in New York City, mainly due to infections, embolisms, overdoses or hemorrhage. Most deaths are considered avoidable. Less than half occur during delivery or within a week afterward.

About 1,200 to 1,500 babies are delivered each year at Woodhull, a large rust-colored building that rises above the rumbling elevated tracks of the J and M trains, where the Bedford-Stuyvesant neighborhood borders Bushwick and Williamsburg.

Because of the deaths of Ms. Semple and Ms. Fields — both of whom were black — Woodhull has emerged as a symbol of New York's maternal mortality crisis.

But for many expectant mothers in recent years, the hospital has been considered an excellent place to give birth because of the strong role midwives play on the birthing floor.

A nurse-midwife who works at Woodhull and is also a researcher, Mimi Niles, said she considers the hospital “one of the safest places to give birth” because of the midwives who attend most vaginal deliveries there.

“I am deeply shocked because I have always promoted the care at Woodhull as exemplary for what a strong midwifery service can do” in a public hospital, she said.

Ms Fields' family had said she had hoped for a vaginal delivery, but when the fetus's heart rate began to drop, doctors had insisted on a caesarean section for her baby's health.