Series of Errors Led to Girl’s Death, State Says

Just over a year ago, 16-month-old Delaney Lucille Gonzalez walked with her family into UCLA Medical Center for routine surgery to repair a cleft palate.

Three days later, she was disconnected from life support and died in her mother’s arms.

“To bring a healthy child in there for surgery so minor,” her mother, Jodi, said recently, clutching a headband she had made for Delaney, “you just don’t accept that she’s going to die.”

The simple explanation is that a breathing tube had been misplaced and had pumped air into the child’s stomach rather than her lungs, according to Delaney’s medical and autopsy records. Because her body was deprived of oxygen, Delaney’s heart stopped. She suffered irreversible brain damage.

But the misplaced tube was just the first in a series of errors leading to the child’s death, according to state health inspectors who reviewed the case in response to a complaint from Delaney’s mother.

According to their report, released last month, the radiology department waited hours before reviewing chest X-rays that would have pinpointed the problem because they were “too busy.” In addition, staff members detached and did not replace a carbon-dioxide breathing monitor that they believed to be broken, gave the girl medications that ran counter to doctors’ orders and failed to alert supervisors as her condition deteriorated, inspectors said.

“There is absolutely no question that ... these violations led to the baby’s death,” said Brenda Klutz, deputy director of licensing and certification at the California Department of Health Services.

Even in the most prestigious hospitals, medical errors sometimes kill patients. According to a landmark report in 1999, 44,000 to 98,000 people die annually in hospitals because of mistakes ranging from performing surgery on the wrong organ to prescribing the wrong type or dosage of medication.

Like Delaney, patients don’t usually die from a single mistake. They die from a series of oversights, faulty assumptions and missed opportunities -- what some experts refer to as a systemic breakdown.

“One single problem is usually not sufficient.... It requires a chain reaction,” said Dr. David G. Nichols, a professor of anesthesiology and critical care medicine and pediatrics at Johns Hopkins University School of Medicine.

With that in mind, leading hospitals and health networks, including UCLA, in recent years have designed ways to check and re-check medical decisions as they are made. They also have made a point of encouraging forthright discussion of mistakes with the aim of correcting faulty procedures.

In Delaney’s case, UCLA doctors met with the Simi Valley family and explained what had gone wrong. But her parents say the hospital never took full responsibility for her death.

On her death certificate, a UCLA physician initially blamed an “airway obstruction” for causing a lethal loss of oxygen to the brain. After recalling the girl’s body for an autopsy, the Los Angeles County coroner changed the cause to include the misplaced breathing tube.

“It’s the result of having the intubation screwed up. They know that very well. They obviously misrepresented the facts,” said Dr. John Cooper, an experienced forensic pathologist from Apple Valley who reviewed Delaney’s death certificates and autopsy report at The Times’ request.

Jodi Gonzalez, a 30-year-old registered nurse, and her husband, Danny, a 44-year-old business owner, have sued UCLA Medical Center and the University of California regents, alleging negligence in Delaney’s care and failure to provide correct information on her death certificate.

UCLA declined to comment on any aspect of Delaney’s care, citing pending litigation. The physicians who participated in her care did not return telephone calls or e-mails seeking comment.

UCLA released a statement, however, saying in part: “Everyone at the UCLA Medical Center, including its administrators, physicians and staff, are profoundly saddened by the death of Delaney Gonzalez. Our hearts go out to the Gonzalez family and to everyone touched by this tragedy.”

The hospital also said it is working with the California Department of Health Services to address problems raised in its inspection report.

“As always, UCLA Medical Center’s first priority is to provide the highest standard in quality patient care and safety,” the statement said.

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‘Bring Her Back’

“Please bring her back,” Jodi Gonzalez recalled telling the anesthesiologist who came to take Delaney to the operating room for her cleft-palate surgery on Feb. 4, 2002. “I will,” the anesthesiologist replied.

The operation was successful, according to medical records. It was supposed to be the first of several to repair malformations on Delaney’s head and face caused by Treacher Collins syndrome, a rare birth defect. The child’s ears were not fully formed, her jaw was small and her cheekbones were underdeveloped.

After surgery, Delaney had difficulty waking up and breathing on her own. She was taken to the pediatric intensive care unit for monitoring, but doctors told her parents that she would be able to go home the next day, the Gonzalezes said.

Jodi Gonzalez said that when she was allowed to see her daughter after 8 p.m., she saw a nurse pull the breathing tube out of Delaney’s nose slightly as she turned to check a machine. The nurse immediately yelled for “Blake” -- Dr. Blake Alban -- then a resident physician in the unit, Gonzalez said.

The child’s medical records do not refer to this incident -- a lapse criticized later by state health inspectors.

The records indicate, however, that Alban ordered a chest X-ray at 8:50 p.m. and concluded that the breathing tube had not been moved. More than three hours later, he ordered another chest X-ray and made the same finding.

On the basis of her own training as a nurse, Jodi Gonzalez questioned Alban’s readings. Delaney’s stomach was “hard as a rock,” which she feared indicated that the breathing tube was pumping air into her stomach.

“They kept doing more chest X-rays,” she said, and they said “everything was fine.”

But after being consulted by telephone three times during the night, supervising physician Irwin Weiss was concerned enough to come in around 3:15 a.m. Three minutes later, Delaney went into cardiac arrest.

In front of the ICU’s double doors, Jodi Gonzalez recalled, she cried as doctors inside performed chest compressions on her daughter. “Do you believe in God?” an intensive-care nurse asked her. “We need to pray for your baby.”

During the resuscitation efforts, doctors performed an emergency procedure in which a breathing tube was placed in her trachea, which was particularly narrow because of her congenital condition, according to medical records. The Gonzalezes recall that Weiss told them it would take time to know if Delaney would recover.

“I knew it was serious. But I didn’t have any idea how serious it was,” Danny Gonzalez said.

In a report he signed the next day, Weiss concluded that two X-rays ordered by Alban had been misread.

The hospital’s radiology department, which typically reviews doctors’ X-ray readings, didn’t examine the records for more than 12 hours after the first one was taken, a delay criticized by the state health inspectors.

Compounding the problem, Weiss noted, staff members also had disconnected a carbon dioxide monitor, which is designed to signal breathing problems, because they believed it wasn’t working.

It is unclear from the medical records whether the monitor truly was not working or whether it had correctly sensed that Delaney was not breathing. In any case, the girl was not hooked up to another monitor until after her heart stopped.

Three days after the initial surgery, the doctors confirmed that the brain damage was permanent and that she had no chance of recovery. “I said, ‘We can’t keep her alive on life support. That’s not fair to her,’ ” Jodi Gonzalez said.

“They gave her morphine, put the baby in Jodi’s arms and then turned everything off,” Danny Gonzalez said.

Delaney died less than an hour later.

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‘Tip of the Iceberg’

In recent years, serious medical errors have attracted increasing attention, especially at prominent hospitals.

In a well-publicized 1994 case, a Boston Globe health columnist, Betsy Lehman, died at the prestigious Dana-Farber Cancer Institute after receiving four times the recommended dose of a highly toxic chemotherapy drug. The mistake was not caught by doctors, pharmacists or nurses; it was discovered 10 weeks later, by a data manager reviewing records as part of a research study.

At United Hospital in St. Paul, Minn., a mix-up last year at a contract laboratory resulted in the removal of a healthy woman’s breasts after she was wrongly told she had cancer. The woman’s biopsy was switched with tissue from another patient; no one noticed until after the double mastectomy.

And in February, a 17-year-old girl died at Duke University Hospital after receiving a heart-lung transplant in which the donor’s blood type did not match her own. The lead surgeon assumed someone else had checked their compatibility.

In its 1999 report citing as many as 98,000 deaths each year resulting from medical errors, the national Institute of Medicine concluded, “Horrific cases that make the headlines are just the tip of the iceberg.” The government advisory body said the annual tally of deaths from medical errors exceeds those from car accidents, breast cancer or AIDS.

In the last several years, many hospitals, consultants and business groups have set out to design better systems to prevent -- or at least to promptly catch -- errors rather than to rely on astute doctors and nurses to correct them at the last moment.

Some hospitals, for example, have designed computer systems to process physician orders. Unlike the paper slips now used, the computer can flag potentially harmful drug interactions or dosage requests. Many hospitals also use bar-code systems to match medications in the right dosages to the right patients.

Those who study medical errors say it is wrong to blame the individuals who commit the errors, when whole systems are probably at fault.

“Even if you fired every person who you think you could attribute blame to, the systems wouldn’t be any safer,” said Maureen Bisognano, executive vice president and chief operating officer of the Institute for Healthcare Improvement in Boston.

In response to the findings of state inspectors in the Delaney Gonzalez case, UCLA pledged to improve its systems. Officials promised that, as a rule, radiologists would be available at all hours to immediately review X-rays for patients in the intensive care unit, and that nurses would receive additional training on administering medication, caring for patients with breathing tubes and advocating for ill patients.

In an unrelated move, the University of California system in March announced plans for an Internet-based system to track trends in medical errors at its five campus medical centers, including UCLA. UC also will establish a “harm score system” for evaluating each error and comparing it with others.

If an error occurs, “we don’t want to put any subsequent patients in harm’s way,” said Dr. Lee H. Hilborne, director of the UCLA Center for Patient Safety and Quality. “Our goal is really to explain honestly what happened to the patient and to fix the problem.”

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Family Letters

Four days after Delaney died, 300 people gathered at a cemetery in Westlake Village for her funeral.

Inside the casket, the girl’s body was dressed in the same pink chenille outfit she had worn to the hospital and a headband with her hearing aid attached -- “just in case she needed it in heaven,” Jodi Gonzalez said. Beside her body were letters each parent had written, a picture drawn by her 3-year-old brother and a stuffed bear.

The casket would not, however, be lowered into the ground that day.

Delaney’s family had relayed their concerns about the girl’s death to their mortuary, which asked the county coroner’s office to investigate. The coroner decided to perform an autopsy after the memorial service.

“We could not bury our child,” Danny Gonzalez said.

After the autopsy, the coroner’s office determined that Delaney had died from loss of oxygen to the brain as a result of an incorrectly placed breathing tube. The coroner based this conclusion, in part, on the hospital’s records.

Separately, the state inspection report last month noted that nurses had given Delaney repeated injections of the potent opiate Fentanyl -- which can depress breathing -- despite doctors’ orders that it should not be given if her breathing slowed significantly.

But some aspects of Delaney’s death remain a mystery. An outside expert who reviewed her medical records for The Times said he couldn’t understand how Delaney had lived for so long without oxygen pumped into her lungs.

“I don’t know how you can paralyze someone and not breathe for them and not have them die in five to 10 minutes,” said Dr. Donald Shaffner, division chief of pediatric anesthesia and critical-care medicine at Johns Hopkins Hospital. “It’s very strange.”

Jodi Gonzalez, who is pregnant again with a girl, is still looking for answers. More than a year after her child’s death, she visits Delaney’s grave almost every day. She cleans the headstone, ensures there are fresh flowers and sometimes brings a ladybug balloon.

“She was my every minute,” Gonzalez said during one recent visit.

The family has left Delaney’s room as it was on the day she went to the hospital. A box of diapers is still there; her headbands remain on the rack.

“There’s no need to change anything like that yet,” Danny Gonzalez said. “She’s still part of our life. She’s still our daughter.”

The couple say their lawsuit against UCLA Medical Center and the UC regents is a matter of principle, not money. In fact, California law limits any damages for “pain and suffering” to $250,000.

“No one should have to go through this ever,” Danny Gonzalez said. “My last memory was handing her to the doctor, giving her a kiss and watching her get carried away.”