Faulty practices at a Los Angeles hospital led to a patient hemorrhaging to death hours after giving birth by cesarean section, a state investigation found.
California Hospital Medical Center in downtown L.A. failed to recognize signs that the patient was bleeding internally, which resulted in the woman returning to the operating room four hours after those signs began to emerge, according to the California Department of Public Health.
The patient, who was at high risk for bleeding, died the same day in March as her C-section, according to the state report. An autopsy found the cause of her death was hemorrhagic shock — severe loss of blood causing inadequate delivery of oxygen to the cells — along with an impaired ability for the blood to clot and stop bleeding, the report indicated.
State investigators called an “immediate jeopardy” situation at the hospital, which means that its failure to meet requirements had caused or would likely cause serious harm or death. The label was removed after California Hospital Medical Center turned in a plan that included reeducating staff in its labor and delivery department on detecting and treating hemorrhages, according to the state report on its findings.
“I would like to express my deepest sympathy to the family for their unimaginable loss,” hospital president Alina Moran said in a statement. “When there is an unexpected patient care outcome, we conduct a review of the care that was 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 in order to prevent similar incidents. … The safety of our patients remains our highest priority,” Moran said.
The hospital did not incur any financial penalties as a result of the findings, a spokesperson said.
In its report, the Department of Public Health faulted the hospital for more than a dozen deficiencies, or failures to meet conditions for federal programs that reimburse hospitals. In some cases, the state agency specifically said that faulty practices had resulted in the death of the patient.
For instance, hospitals are supposed to maintain an ongoing program to improve their performance, but the state team found it had failed to properly keep up such efforts. Hospital staff told the state that California Hospital Medical Center had not followed its own processes for managing obstetric hemorrhages.
“This deficient practice resulted in [the patient’s] death four hours after a Cesarean section delivery,” the state team concluded.
State investigators also found there was a 1½-hour delay in getting the patient a second transfusion of red blood cells. And the hospital failed to inform its governing body about the patient who had hemorrhaged to death, hampering its ability to push for improvements, the state found.
The state team also found other problems involving other patients at California Hospital Medical Center during its April review, including failing to take steps to prevent patients from developing potentially deadly blood clots.
The L.A. hospital was founded more than a century ago and is now part of Dignity Health, one of the biggest healthcare systems in the country. The California Department of Public Health has issued other findings about the facility over the past year and a half: Last summer, a sponge was left in the vagina of a patient with endometrial cancer who was being prepared for surgery and was not removed until the following day, in violation of hospital policies, it found.
Earlier this year, state investigators faulted another Southern California hospital — Centinela Hospital Medical Center in Inglewood — for lapses that could jeopardize patients in its labor and delivery unit. The findings followed public protests and calls for investigation of the death of April Valentine, a 31-year-old woman who delivered a baby at Centinela Hospital. Black women like Valentine have been at higher risk of dying of 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 its treatment of Black women who give birth there. The investigation follows allegations of discrimination after the death of Kira Dixon Johnson, who died after going to Cedars-Sinai to deliver her second son.
The state report did not name the patient who died after the C-section at California Hospital Medical Center.